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Problematic Transitions of Care: Elderly Hospital Discharge & Readmissions


Everyone looks forward to being able to return to the comforts of home after being hospitalized. However, too many patients will quickly return, especially those over age 65 and with multiple conditions.


Nearly 18 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, and patients with multiple chronic conditions are readmitted at rates as high as 25 percent, according to Medicare Payment Advisory Commission (MedPAC) estimates.

Within 90 days of hospital discharge, as many as 35% of Medicare recipients will be readmitted to the hospital.

Those at highest risk have certain conditions such as heart failure, COPD (Chronic Obstructive Pulmonary Disease), Psychoses, Intestinal Problems or recent surgery; those taking 6 or more medications; and those being discharged on weekends or holidays. Older patients who live alone were twice as likely to be readmitted if they did not have supportive community services such as home care.


Research on care transitions suggests that as many as 20 to 30 percent of adverse events following discharge are preventable, and another 30 percent could be minimized/improved.

“Decentralized responsibility is a central defect of the discharge process”, says Judith Black, M.D., MHA, medical director of senior products at Highmark Blue Cross Blue Shield. After a hip replacement, for example, an orthopedic surgeon writes orders, a primary care physician writes orders, and a case manager issues instructions. Patients are often confused and overwhelmed by the process, and even family caregivers often find they do not receive much communication or feel they understand the process.

Communication problems are thus one primary causes of problems after discharge. In a study published by the Journal of Hospital Medicine, more than half of patients over age 70 years responding to a post hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Poor communication and follow up care lead to issues like medication errors, falls, infections and dehydration. Even when communication is good, patients are often groggy, medicated and overwhelmed. This is why it can be vital to have an advocate there to hear the instructions, ask questions and answer the patient’s questions later. Written instructions in laymen’s terms help as well.

Lack of good follow-up care and supportive services is another cause of preventable readmissions. Studies have indicated that 40-50% of readmissions are linked to lack of community services/follow-up care. For patients in the 85+ age range, more than half require assistance with daily needs in the period following hospitalization. Family caregivers may not be prepared to care for a loved one who needs more physical assistance in a weakened state. The logistics of staying with someone while they are weak or on heavy medication and handling other responsibilities may be too much. Patients without local family support need coordinated services after they leave the hospital such as help with activities of daily living, household help, meal preparation, medication management, physical therapy, transportation to appointments.


Our sister company, EasyLiving, Inc. provides Pinellas County home care support services such as personal care (help with bathing, dressing, grooming), household help, medication management, transportation and a special Transitions of Care Program to help immediately after hospital discharge.

Aging Wisely’s patient advocate care managers can help with the hospital discharge process, ensuring a smooth transition for you or your loved one. We invite you to review our article on elder patient advocacy and contact us today for help.

Look for our future articles on solutions for hospital discharge problems, including a checklist of things you can do, resources, and ways to be prepared.

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