Days after she was discharged to her Saugus home from Beth Israel Deaconess Medical Center after being treated for pneumonia, Carol Sewell got a call. A nurse working for both the hospital and her primary care doctor began checking in on her regularly, sometimes three times a week: Did she know about her follow-up appointments? Could she get a ride to the doctor’s office? And had she filled her prescriptions?
“It kept me doing things that I should be doing that I might not have,” Sewell said. “She’d ask questions. I’d have to have the answer.”
Comments
Hospitals are focused on treating acute conditions. As the population ages, we will have more people with multiple chronic conditions. Often these people have a prolonged course with frequent exacerbations and little real improvement of the underlying conditions with a hospital admission.
Even with the best hospital treatment, many will be readmitted in a short period of time. It would make sense to keep the complex patient a little longer.
Nevertheless, there is pressure to keep admissions short and now to develop ways to prevent re-admission. As in home non-medical senior care providers, we see seriously ill patients sent home with little preparation or warning. The best way to manage these people is often with continuous low level monitoring and support not only to keep them out of the hospital but to maximize their lives. We have seen many clients become happier and more active, with decreased hospital and physican visits (demonstrated in published papers) when they have help and someone to interact with. Things as simple as nutrition exercise, medication reminders and help with day to day tasks all matter.
We encourage seniors and their families to get a little help early on, before the crisis and hospitalization. It can go a long way towards preventing the first and subsequent admissions.