Skip to main content

How can nurses improve outcome for patients after a hospital stay

By
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.


Comments

Post a Comment

Popular posts from this blog

Keeping Elderly Minds Sharp and Active

By Anonymous
To stay in line with the last post; as important as it is to eat healthy, it is just as important for elderly adults to stay socially and mentally active! It is almost a cliché to think about an elderly person sitting in their recliner every day watching their “Soaps”, “Murder She Wrote” or their court room shows for hours on end. This is sometimes what people think of when it comes to the daily activities of an elderly person living independently at home. This would obviously not be healthy and by no means does this happen all of the time. However, it would be easy for someone to get into this habit as it almost gives them an escape from reality and allows them to form “bonds” with characters in the shows. It is critical for them to find other activities to stay happy and healthy and there are many other daily activities that they can do alone or with another person to keep their mind sharp and social skills intact. It is important for elderly individuals to keep their brains...
Post a Comment
Read more

Why I became a caregiver? By: Beverly Hughes

By
Why I became a caregiver? By: Beverly Hughes Being a caregiver has been my passion in life. I started giving care when I was just 12 years old. That was a good 19 years ago, but it feels like it was just the other day. Back then, I would typically spend nights and weekend at my best friend’s house. Her mom had live-in clients. My thinking then could be explained in two short sentences: Wow, I can't wait for Friday. And then, TGIF, I get to spend the weekends staying up late, watching movies and having limited or no rules. While all this seemed to be the life, it wasn't until one night when I heard a little old lady praying and thanking God just how thankful she was to have a caregiver. Some time went on and I didn't think much of it. Until one day, that same little old lady took my hand and said "dear someday this will be your mom". From that day on, I provided care in any way I could, to anybody in need. Brushing dentures and washing urinated clothes ...
Post a Comment
Read more

Becoming a caregiver By: MaryAlice Callahan

By
Becoming a caregiver By: MaryAlice Callahan I became a caregiver because I knew that it was a career that I would be great at.  I worked on Hematology/Oncology for a few years and would see people that needed my help, but because I was a secretary and not a licensed caregiver I was not allowed to help.  It really bothered me because I saw the hurt and pain in their eyes and I would want so badly to be able to fulfill their request, big or small.   After my years at the hospital, I became a Medical assistant for an OB/GYN in South Burlington. I worked alongside with her, and again was in the presence of people who at times needed  tremendous support, and this time I was able to help them.  I also worked as a cosmetic laser tech in her office, and I loved the feeling when they saw their acne scars erased or spider veins that have embarrassed them forever disappear. I felt that there was an intimate exchange of energy between myself and them.  There...
Post a Comment
Read more