About 17 out of every 100 Medicare hospital stays in 2018 were followed by another stay within 30 days, according to the federal Agency for Healthcare Research and Quality. Readmission is a real problem and it can only be tackled by a good plan for home care. This guide explains why seniors end up back in the hospital and what to set up before discharge day. It also shows how nursing and aide care can lower the risk.
The weeks after a hospital stay are often shaky. Your parent might be weaker than before and taking new medicines. There is also a new set of instructions to follow, usually in a home that was not set up for recovery.
Many readmissions begin with small gaps. Instructions get lost between the hospital and home, follow-up visits get missed, and no one is watching closely when something changes.
Transitional care at home fills those gaps with regular, trained eyes on your parent’s recovery.
Bronx families also juggle work, long commutes and small apartments while they help a parent recover. Even a loving family cannot be there around the clock, which is exactly why a care team that visits on a set schedule gives you reliable backup. So you are not guessing about what to watch for.
The weeks after a hospital stay are often shaky. Your parent might be weaker than before and taking new medicines. There is also a new set of instructions to follow, usually in a home that was not set up for recovery.
Many readmissions begin with small gaps. Instructions get lost between the hospital and home, follow-up visits get missed, and no one is watching closely when something changes.
Transitional care at home fills those gaps with regular, trained eyes on your parent’s recovery.
Bronx families also juggle work, long commutes and small apartments while they help a parent recover. Even a loving family cannot be there around the clock, which is exactly why a care team that visits on a set schedule gives you reliable backup. So you are not guessing about what to watch for.
Most of these problems can be caught early with proper attention:
Good discharge planning for home care starts in the hospital. Ask a nurse or social worker to help you with each item below.
Bring these papers to your first call with any home care agency. The more we know before the first visit, the better the care plan fits your parent.
All Care Living Assistance Services is a Licensed Home Care Service Agency regulated by the New York State Department of Health. Our nursing, aide and social work teams can work together so your parent is not recovering alone.
Nursing
Our in-home nursing team includes registered nurses (RNs) and licensed practical nurses (LPNs). A registered nurse visits first for an assessment, and then builds the care plan with you and your parent.
Aides
Home health aides and personal care aides help with daily needs like bathing, dressing, getting around the home and household tasks tied to care.
Social work
Our social work team offers support, advocacy and resources. Families can lean on them when they need help coordinating with the hospital and their parent’s plan.
How it starts: The registered nurse visits your parent at home for a clinical assessment. Together we build a care plan that covers medications, safety at home, daily tasks and the support your family wants. We then match your parent with an aide who follows that plan.
Note: The plan does not stay fixed. Your parent’s strength and needs will change as recovery moves along, so the nurse reviews the plan and adjusts it when something changes.
Fast approval depends on starting early. These steps help:
If you have questions about Medicaid, our specialists and social workers can walk you through applications and recertification.
Every recovery is different, so follow the instructions your parent’s doctor gave you. These changes are worth reporting to the nurse or doctor the same day:
In an emergency, call 911. When a nurse is involved in your parent’s care, tell the nurse what you see so it gets noted in the care plan.
Our office is at 2227 Westchester Avenue in the Bronx. We serve families across the Bronx, Brooklyn, Manhattan, Queens and Westchester.
Start dates depend on the nurse’s assessment, your parent’s needs and any approval from a plan. The best step is to call as soon as you know the discharge date, ideally before your parent leaves the hospital. We can then tell you what to expect for your family.
