Returning Home Program Care Services

A review of the most common transitional care programs used in medical facilities highlighted a number of common important factors and conditions that can help prevent a readmission once a patient has returned home. The Home Instead Senior Care® network developed a similar list when it surveyed discharge planning and transitional care coordinators about what care they believe must happen once a patient returns home from a hospital or other medical facility stay.

To help meet these needs, the Home Instead Senior Care network created the Returning Home℠ Program. The details of the program components are outlined below.

Thoughts from the Experts

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Owners, health care professionals and Home Instead Senior Care clients discuss the important role that Home Instead has played in the lives of patients coming home from the hospital. A patient needs someone to make sure they take their medicines, get to the doctors and eat correctly, and assistance with their discharge instructions will make a difference in the patient being successful at home or returning to the hospital.

Discharge coordination and execution

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Before a transitional care client is discharged from your facility, consider suggesting a professional caregiver who can serve as a "transitional care coordinator."  This person will conduct an initial meeting with hospital discharge planning staff to obtain a transitional care plan with detailed care instructions that will be used by the caregiver throughout the transitional care period. Items to be included in the Transitional Care Plan should include:

  • Family and physician contact information
  • Medical follow-up appointment calendar
  • List of dietary restrictions and preferences
  • List of all medications and instructions
  • Specific or unique warning signs to watch for
  • Identification of any additional services requested or required 

Medication reconciliation

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To prevent complications and ensure the patient's dosing compliance ensure that your patient's caregiver will:

  • Pick up prescriptions
  • Ensure the medication is taken as directed
  • Make sure all prescriptions (new and old) are filled at one pharmacy to help avoid any adverse reactions
  • Encourage use of an organized pill box
  • Track medications with a form that lists all of the patient's medications, including over-the-counter items, with dosage descriptions and special instructions 
  • Help patients understand they must continue to take all medications as prescribed by their doctor even if their health is noticeably improving 

Follow-up physician visit assistance

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An ideal returning home program will offer solutions for your patients who lack the ability or means to get to and from post-discharge follow-up medical appointments.

Look for a transitional care provider that will:

  • Call to make appointments
  • Provide transportation
  • Sit in on visits to hear the physician's or other health care providers' recommendations
  • Share the Transitional Care Plan and medication information during medical visits
  • Relay information back to the family and other health care providers

Nutrition and dietary management

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Lack of transportation, inability to leave the home, medications and the cumulative effects of surgery and other medical procedures can leave seniors who have returned home from the hospital with no appetite and/or no ability to get to the grocery store. The end result likely is poor dietary and nutrition habits at the time when healthy eating is vital to their recovery.

The returning home program caregiver should agree to:

  • Shop for healthy ingredients
  • Prepare meals
  • Coordinate timing of medications that need to be taken with food
  • Monitor compliance with dietary restrictions

Manage complications and predicable events

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A key element of any good returning home program is the opportunity it provides to identify warning signs of trouble or health decline as early as possible so that intervention can occur and prevent a readmission.

Be sure the professional caregiver has been trained to:

  • Monitor recovery progress
  • Identify "red flags" outlined in the patient's recovery care plan
  • Take appropriate actions in a timely manner

Record keeping

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A Returning Home pilot program conducted by the Home Instead Senior Care network found that keeping track of a patient's recovery process in a document and sharing that information with medical professionals and other caregivers can help improve care coordination and patient outcomes as well as reduce readmissions.

Details to track include what and how much the client eats, medication taken, activities, and the level of assistance provided each day. This data can benefit individual patients and potentially serve to identify additional programs and services that could help health care professionals create better transitional care plans and reduce overall hospital readmissions.