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How can nurses improve outcome for patients after a hospital stay

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By: Mohamed Basha, RN CMC BA AAS AA
Care Manger Certified & Aging Life Care Professionals

As a fellow nurse, I am always looking for ways to improve my patients’ quality of life, be it in the hospital, nursing homes, or in their own homes.  I also make it a priority to educate myself and my co-workers on services available in the community for my patients and their families.  In a recent meeting with a group of fellow nurses, I was astonished to find out that many did not know or understand the difference between non-medical home care and home health care, nor did they know what services were offered to their patients during their discharge planning.  It is imperative that proper discharge planning incorporates all services that are available to a patient when there are discharged from the hospital.
                                   
Numerous studies have shown the importance of post-discharge care in preventing readmissions. In particular, using home care with a professionally-led transitional team has been shown to significantly reduce readmissions.  A study conducted at Baylor Medical Center found that a nurse-led transitional program reduced 30-day readmission rates by 48%.

According to the New England Journal of Medicine, 1 in 5 Medicare patients discharged from the hospital are readmitted within 30 days. Most readmissions are seniors and they often occur because of medication problems, nutrition mismanagement, falls in the home, and not following up with the doctor. Safety issues, nutrition and hydration challenges, limited support, and overwhelming responsibilities can make returning home from the hospital a difficult transition.  Often these patients do not meet the criteria for VNA home health care such as skilled nursing services and physical therapy services.  However, non-medical home care services offer unique solutions to individual challenges. 

As Vermont’s only nurse-owned homecare agency, our services are supervised and coordinated by RNs.  Every client is assessed by an RN, and an individualized care plan is developed.  Making homecare part of the discharge plan can ultimately reduce hospital readmissions by optimizing wellness, independence, and safety, while keeping seniors where they want to be: at their home.

TLC Nursing Associates provides non-medical homecare, enabling seniors to transition and remain safely in their place of residence.  From a few hours a week to around the clock, including a live-in option, our experienced caregivers can assist with the tasks of daily living such as medication reminders, meal preparation, light housekeeping, shopping, transportation and companionship.  Personal care including help with bathing, dressing, toileting and ambulation are also part of what we do.

Please take a moment to review this comparison chart that explains all the non-medical homecare services that are available in the community and how one differs from the other.  If you have any questions or concerns, please contact me at 802-735-1123.  I will be happy to come to your floor to meet with you and discuss our services personally, or arrange services for your patients when the need arises.


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