Welcome Wisdom

Reducing Rehospitalizations: Insights from a Care Manager

by Felicia Juntunen, MA, CMC, Director of Care Management

Imagine finally being discharged from the hospital, feeling a sense of relief, only to find yourself back in the emergency room just weeks later. This frustrating cycle happens all too often for many patients, especially those dealing with complex or fragile health issues. Not only does it disrupt recovery, but it also puts a strain on the healthcare system and drives up costs. An Aging Life Care Professional can help break this cycle and ensure a smoother recovery, significantly reducing the chances of readmission.

Aging Life Care Professionals, or care managers, play a crucial role in today’s healthcare environment. They act as a bridge between medical providers and community resources, leading to better outcomes for their clients. Their job involves comprehensive care coordination, with a focus on communication and advocacy. By ensuring these aspects are covered, they help prevent unnecessary rehospitalizations and improve overall patient outcomes.

Avoiding rehospitalization begins with careful planning and coordination. Care managers start by thoroughly assessing a client’s needs and creating personalized care plans, which they continuously refine as needed. They also educate clients and their families about available community resources and guide them on how to access these services. Managing medication is another critical area they handle, ensuring accurate communication between the patient’s old and new care settings. They keep the lines of communication open with medical providers to relay important information about symptoms and medical history, ensuring continuity of care. Additionally, they facilitate communication among the various healthcare professionals involved in the patient’s care.

Care transitions, or the movement between different healthcare settings—such as from a hospital to a skilled nursing facility, or from these settings back home—are crucial moments in a patient’s rehabilitation. Effective management of these transitions is essential to avoid complications and ensure a smooth recovery. Aging Life Care professionals excel in this area, guiding patients through each stage of their care journey. They address common challenges like medication errors, communication breakdowns among healthcare providers, inadequate follow-up care, and insufficient support from family or caregivers.

For patients recovering from illness or surgery, these challenges can disrupt their progress and potentially lead to relapse. For example, a patient might return home and struggle with preparing meals or accessing medications due to transportation issues. Care managers work proactively to identify and resolve these obstacles, aiming to prevent setbacks and rehospitalization.

Care managers use several effective strategies to support their clients and reduce the risk of rehospitalization. They keep everyone informed about the client’s status during hospitalization and help facilitate communication between hospital staff and family members. They also provide essential information for developing safe and effective discharge plans and assist in finding suitable alternative care settings when home care isn’t feasible. Helping clients understand their discharge plans and supporting follow-up care, including home health services and medical appointments, is another crucial aspect of their role. They manage medications post-discharge, address polypharmacy issues, and adjust care plans as necessary.

Through these efforts, Aging Life Care professionals make a significant impact on improving patient outcomes, reducing rehospitalization rates, and ensuring a smoother transition between care settings. Their expertise in coordination and communication is invaluable in helping clients achieve the best possible results.