Joe Richards, is an avid chess player and former Air Force pilot. Because he’s always taken good care of himself, he is a healthy 82 year-old. A fall landed him in the hospital for 7 days. Leaving the hospital was difficult and confusing—new prescriptions, new instructions, questions about his situation at home, needing to arrange for new equipment (toilet riser). Taking in all these things and more was challenging when added to the short time the discharge planner had to speak with him. During discharge, he was so focused on getting out of the hospital, he didn’t listen as carefully as he should have and missed the instructions to stop taking all his old medication and take only the new prescriptions. Fortunately, his error was caught during the hospital’s follow-up call, 24 hours later.
Did you ever think transitioning from hospital to home could be dangerous? Recent research from the National Council on Aging found a person’s age is more a risk factor than the cause of the hospitalization.
In the following interview, Stephanie Johnson of Home Care Assistance, shares the best ways caregivers for older adult loved ones can avoid common mistakes during and after hospital discharge. As Director of Client Care, Stephanie works with many families to help older adult clients safely transition home from the hospital and return to independence, when possible.
Q. Stephanie, what puts older adults at greater risk during the hospital discharge process? Most have been in the hospital before, so why is the situation different?
A. First, the hospital discharge planning process is the point at which a person receives instructions on how to care for themselves after they leave the hospital. As hospitals and our medical system work to reduce costs, patients are released earlier in their healing process and expected to either recuperate at a skilled nursing facility, or at home.
Older adult patients who go home need a reasonable ability to complete post-hospital health tasks themselves or keep recovery on track with support from family or professional caregivers. As you might imagine, being able to fully understand and comply with the discharge planner’s instructions is extremely important and determines the success and speed of recovery.
The discharge planning process is difficult for most patients and harder on older adults. On top of whatever brought the senior to the hospital, most already have serious medical conditions which might cause depression or confusion, both of which conditions can worsen with hospitalization and make paying attention to information more difficult. In fact, researchers have found 77% of seniors have at least 2 chronic conditions, such as heart disease and diabetes and adults 80-84 years old take an average of 18 prescriptions per year, while typically taking 5 or more at any one time, [National Institutes of Health (NIH)].
Additionally, an older adult might have a more challenging time understanding hospital discharge instructions because of:
- Anxiety about being in the hospital and a deep desire to return to the comfort of home
- Pain or confusion due to medication or illness
- Alzheimer’s or other dementias not recognized by hospital personnel (a common occurrence)
- A lack of fluency on healthcare and self-care, so unable to make sense of the information given by discharge planners
- Disorientation and heightened difficulty if don’t have glasses or hearing aids, (or base medications as in the case of Parkinson’s disease)
- Needing more time to process information than the discharge planner allows
Q. Isn’t the discharge planning process getting better because hospitals are focusing on it?
Yes. There is more post-discharge follow-up with patients, but the whole process can be much more successful for older adults when a caregiver (family or professional) has an active role.
Q. What do you mean by “active role” for caregivers? Do hospitals allow this?
A. Yes, there is a new Nebraska law called The Assisting Caregiver Transitions Act which lets a hospital patient specify a caregiver who can be part of the discharge process and be taught how to care for the patient, with both written and live instruction, for things like wound care, injections and medication management. It’s a tremendous step forward. More information about this law is available from AARP Nebraska at 1-866-389-5651.
Q. What makes the hospital to home transition so difficult?
Recovery from hospitalization is complex and an older adult with many health conditions often has a difficult path going from hospital to home. Common mistakes:
- Starting the discharge process too late. Start as soon after admittance as possible to create a post-hospital support system for your loved one. Arranging family or professional caregivers for a minimum of 2-3 days after release is essential.
- Allowing your older adult loved one to attend the discharge planning process alone. Older adults fare better with an advocate who understands the situation at home, is able to take notes, and can fully comprehend instructions.
- Adding new medications prescribed during the hospital stay to the old medications at home, or not informing the hospital of all of the medications, (including prescribed, over-the-counter, and supplements), being taken.
- Returning to old behaviors once back at home, such as eating too much salt when should be on a salt-restricted diet.
- Underestimating the need for support. Older adults may try to do too much, too soon because they don’t believe they need help or don’t wish to pay for it even when funds are not the issue.
- Refusing to follow discharge instructions and comply with medical equipment use. Older adults may refuse to take medications as prescribed, opt out of follow-up appointments, or fail to secure needed medical equipment, like a hospital bed or walker. In many cases, a senior needs help from family or professional caregivers to be encouraged and supported in complying with instructions and to ultimately return to their own highest possible level of independence.
- Failing to use the hospital’s resources due to pride or fear. When the hospital follow-up call or visit comes, encourage your loved one to be honest about medication side effects, pain, and other difficulties. One purpose of the discharge process is to define when to be concerned about pain or a side-effect, when to call the doctor with a problem, and what constitutes an emergency.
Q. Layering new medications on top of old medications sounds really dangerous. I’ve read this is a huge problem in the U.S. What is the best way to handle this situation?
A. This is a very complicated issue, which requires an informed patient and all the various medical professionals to work together—a tall order. Unfortunately, 55% of seniors take medication incorrectly, according to NIH.
The Omaha World Herald recently published an article from Kaiser Health News on this subject, [September 11, 2016]. The opening paragraphs of the article had this example of overmedication: “And then there was Lola Cal, 74. She was in the hospital for pneumonia and had trouble breathing. Her records showed she was on 36 medications…several of which could suppress [her] breathing.”
While we can’t manage medications for clients, Home Care Assistance Care Managers coordinate pharmacy reviews of medications when clients are seeing multiple specialists and support clients in appointments with doctors so medication can be taken as prescribed. Communicating a list of all medications taken, and for what reason, is an important part of helping doctors understand the whole picture of an older adult’s healthcare.
Q. What else do you suggest for families?
A. Several great resources on successful hospital discharge:
- Our company website has a brief article, “10 Tips for a Success Hospital Discharge,” which is a useful list of points to cover with discharge planner before leaving the hospital.
- A long, detailed article which covers every aspect of the discharge planning process, from the Family Caregiver Alliance: https://www.caregiver.org/hospital-discharge-planning-guide-families-and-caregivers
- A series of easy-to-print tools for the hospital to home transition: http://hospitaltohomecare.com/pages/hospital.html
- Area Agencies on Aging with care management services can also help with the transition home from the hospital. In Lincoln, NE, call Aging Partners, 402-471-7070 and in Omaha, NE, call the Eastern Nebraska Office on Aging, 402-444-6444.
Q. Anything else you’d add?
A. My number one suggestion: don’t leave the discharge planning meeting until you have written copies of all the instructions for your loved one, including appointments, details about medications, and needed equipment. It’s the hospital’s job to help patients make the hospital to home transition safely. If you’re supporting an older adult loved one and need more information or help to learn to do a healthcare task, ask the discharge planner.
Home Care Assistance understands “hospital to home”. Our Care Managers work with your medical team and you to help you recover as quickly and completely as possible. We can help you create new routines so you’ll find yourself back to living, not back in the hospital. Call 402-261-5158 to speak to a Care Manager in Lincoln or 402-763-9140 in Omaha. Our websites are helpful, too: HomeCareAssistance – Lincoln and HomeCareAssistance – Omaha.