Elder Care Blog

How to Prevent Readmission to the Hospital

If your elderly parent has been recently discharged from the hospital, they are at a high risk of being readmitted. One in five elderly are readmitted within 30 days of discharge for reasons varying from congestive heart failure, pneumonia, and infection. The elderly are also more likely to experience falls after a hospital stay due to weakness and confusion which often result in readmission. The best prevention against these health conditions is careful monitoring and setting realistic expectations. The elderly take longer to “bounce back” from a hospital stay. The loss of routine, stress of being in a medical setting, change in diet, and fear can take a toll on their overall well-being – physical, mental, spiritual and psychological.

The care that is provided during the transition period from hospital to home is important and various models and strategies have been developed and researched. Some strategies include forwarding the discharge summary to your parent’s primary care physician right away to keep them in the loop, scheduling follow-up appointments before the discharge even occurs, inquiring about follow up nursing care through home health services with the hospital discharge planner and arranging for someone (family or home care agency) to be in the home at least for the first 72 hours after discharge (http://news.yale.edu/2013/07/16/six-strategies-reducing-hospital-readmissions-among-elderly).

The Affordable Care Act (ACA) has focused on this problem by imposing penalties on hospitals with high readmission rates with the theory that this will prevent the elderly from being discharged prematurely. The ACA also created the Community-based Care Transitions Program in which hospitals partner with community organizations to provide oversight and services to newly discharge patients covered by Medicare as they transition from hospital to home. The Centers for Medicare and Medicaid Services will oversee this program. The goals of the Community-based Care Transitions Program are:

  • To improve transitions of the elderly from the inpatient hospital setting to home or other care settings
  • To improve quality of care
  • To reduce readmissions for high risk elderly patients
  • To document measurable savings to the Medicare program


Ask your hospital discharge planner about this Medicare program and if there is a provider authorized by the Centers for Medicare and Medicaid Services to administer the Community-based Care Transitions Program in your county.