Recovering at home
For many older adults, a hospital stay is just the first step in recovering from a serious health issue. What happens in the days and weeks that follow can be just as important — and in some cases, even more so. Studies show that many seniors end up back in the hospital not long after being discharged, a situation doctors refer to as “readmission.” In fact, the Agency for Healthcare Research and Quality reports that nearly 16% of Medicare patients ages 65 and older are readmitted within 30 days of discharge. While not all readmissions are avoidable, many are. Taking the right steps can help you stay well at home and out of the hospital.
Understanding the risks
Dr. Jacob Thomas, a hospitalist at Winona Health, has worked with hospitalized patients for more than a decade. He says seniors are vulnerable to readmission for several reasons. “Some health issues just carry a higher risk — things like congestive heart failure or severe COPD (chronic obstructive pulmonary disease),” Dr. Thomas explains. “These are chronic conditions, and while you can get them under control in the hospital, the symptoms can come back quickly once the patient is home again.”
A nurse practitioner specializing in internal medicine at Mankato Clinic, Rebecca Corrow, APRN, CNP, often sees the same pattern. “The most common reasons I see seniors readmitted to the hospital are for congestive heart failure or COPD exacerbations,” she confirms. She also notes that treatments which suppress the immune system, like those for cancer or autoimmune diseases, can raise the risk of readmission.
But serious illnesses aren’t the only factors that increase risk. As we age, our bodies become less resilient, making it easier for things to go out of balance. Those dealing with frailty and weakness face an even higher chance for hospital readmission. Memory problems and the stress of managing new medications can also increase vulnerability, particularly for those who live alone or don’t have help nearby. Knowing what to expect and planning ahead can make a big difference. Here are a few core considerations to keep top of mind:
1. Support at home
Having a strong support system at home can make all the difference during recovery. “Sometimes we see patients who are trying to manage serious health problems by themselves, and it’s just not realistic,” says Dr. Thomas. Whether it’s a spouse, adult child, friend or home health aide, the right help at home can ease common challenges like managing medications, tracking symptoms and staying on top of daily routines.
Corrow agrees, noting that social isolation is a major risk factor for readmission. People with little to no support may struggle to get to appointments, stay hydrated and nourished, or keep up with medications. “Stay in close communication with your primary care provider,” she says. “They can connect you with a care manager or social worker who can offer additional resources if needed.”
She emphasizes that simple, consistent habits — like eating regular meals, staying mobile and following fluid recommendations — are often the most effective for recovery.
2. Medication mix-ups
One of the biggest risks after a hospital stay is medication mismanagement. Patients may forget to take their medications, run out unexpectedly or skip doses due to cost.
Corrow says hospital discharge is one of the highest-risk times for medication errors to occur. That’s why she encourages patients to set up an appointment with their primary care provider soon after discharge.
“Bring all your pill bottles and medication lists into your doctor’s office,” she suggests. Your provider can walk you through any changes and help clarify your daily medication routine. Family members and caregivers can also play a vital role by setting up pill organizers, offering reminders and reviewing medication instructions together.
3. Follow-up care
Scheduling and attending follow-up appointments is one of the most effective ways to avoid a return trip to the hospital.
These follow-ups allow healthcare providers to make sure the patient is recovering well, adjusting to new medications and addressing any new or worsening symptoms. They also give patients a chance to ask questions and catch potential problems early.
Corrow emphasizes that this is the time to review any new care needs that may not have been obvious at the time of discharge. “This appointment is also where you can go over your plan for additional follow-up with any specialists,” she adds, encouraging patients to bring a loved one for extra support. “Taking notes and having someone else to help remember things discussed at the follow-up appointment can go a long way in improving outcomes.”
KNOW YOUR MEDS
Before leaving the hospital, ask:
• What new medications am I starting?
• When and how should I take them?
• What if I miss a dose or have side effects?
• Who can I call with questions?
Need extra help managing your meds? You may qualify for a free Medication Therapy Management (MTM) review. Click here to learn more.
Staying proactive
While some readmissions are unavoidable, many can be prevented by staying engaged, informed and connected to the care and support you need. “We know our patients want to stay home, and we want that for them too,” Dr. Thomas explains. “It really takes a team effort to make it happen, between the hospital, the primary care provider and the patient’s support system.”
As he puts it, “An ounce of prevention is worth a pound of cure.” Planning ahead, listening to your body and reaching out before symptoms escalate can make all the difference.
“Don’t wait; reach out,” Corrow echoes. If something feels off, you’ll want to get ahead of it rather than waiting for a situation that could send you back to the hospital.
