11/10/2011 01:47 pm ET | Updated Jan 10, 2012

Helping a Sick Loved One Transition From Hospital to Home

The day a family member enters the hospital is the day to start planning for the trip back home. Of course nobody wants to go to the hospital in the first place, but it's clear that as hospital stays get shorter and shorter, an increasing burden is falling on family caregivers: those people who will be responsible for helping a friend, neighbor or family member when they first get out of the hospital and possibly for some time afterward.

Frances* is the family caregiver for her mother, Patricia, who has diabetes and recently had a hospital stay following surgery for a broken hip. The surgery went well, and Patricia was eager to be discharged and get home to her house and her cat, Billy. But as hopeful as she was upon leaving the hospital, Patricia had problems after her arrival home.

The first few days after hospital discharge mark an important time -- the transition from one care setting to another, when a patient is especially prone to adverse events, and possibly even re-hospitalization. In a 2009 study of Medicare beneficiaries, 20 percent of the almost 12 million Medicare patients who had been discharged from a hospital were re-hospitalized within 30 days, and 34 percent were re-hospitalized within 90 days.1 Doctors and insurers recognize this vulnerable time, and as a result, call in-home care agencies such as the Visiting Nurse Service of New York where I work, to assist patients and their families after hospital discharge.

In Patricia's case, she was told to make an appointment with her surgeon and her primary care physician as soon as possible after leaving the hospital. Unfortunately, her daughter Frances was not present at the hospital discharge interview and did not hear those instructions. "I certainly didn't see them in the big packet of paperwork Mom had in her hands when we finally left," Frances says. Relieved to be back on her own home turf, Patricia felt pretty good for a few days after returning home so, like many people, she delayed making her appointments.

Patricia also had written orders from her doctor about the pain medications she was supposed to take, but when she got home she found it difficult to keep to the schedule that had been set in the hospital. By the fourth day after discharge, Frances could see that Patricia was not doing well. Her hip was hurting, and she seemed exhausted and without energy.

After dinner on that fourth day, Frances called the doctor and explained about her mother's fatigue and listlessness; the doctor told her to take Patricia into the emergency room right away. Patricia resisted, and Frances, dreading what she feared would be an all-night wait, considered not going at all, but "I started to get scared that something might really be wrong," she says, so off they went, against Patricia's wishes.

In the emergency room it became clear that Patricia had not re-started her insulin, which had been suspended during her hospital stay, though she had been instructed to begin again upon returning home. An emergency room nurse spent time that night with Frances and Patricia discussing the discharge instructions and medications, and then, the next day, a home-care nurse was called in to do a full medications review when Patricia got home. Three days later, taking the proper medicines in the right doses, she was feeling much better, and starting to move around the house again.

The Transitional Care program at VNSNY is designed to ensure coordination and continuity of health care as patients transfer between different locations, usually from hospital to home. It also helps reduce preventable re-admission to the hospital. The program is multi-faceted, but the primary focus is to:

• Assure follow-up appointments with medical providers for all patients within 7-14 days of discharge;

• Develop an "action plan" for recognizing symptoms that might need early intervention;

• Identify patients at risk for hospitalization and "front-load" contact with them right after hospital discharge;

• Teach self-care techniques; and

• Reconcile medications using a patient-friendly medication list.

As a family caregiver, it's vital to know that there are things you can do for a family member coming home from the hospital to reduce their chances of going back in. Sally Sobolewski, director of practice improvement at VNSNY, has the following recommendations for family caregivers:

Have an appointment set up with your family member's primary care physician for when they get home from the hospital. Ideally, this appointment should be within seven days of arriving home, but certainly no later than 14 days. "Many people hesitate to make this appointment, because they think, 'I just got back from the hospital,'" states Ms. Sobolewski, "but the few days after hospital discharge is the time most adverse events are likely to happen. It's important that the physician who oversees your family member's care be aware of what went on during their hospital stay, and is monitoring them during this transition period."

Reconcile your family member's medications within the first 24 hours of arriving home. Medication reconciliation means looking at what medications were prescribed and brought home from the hospital, and comparing them to the medications the patient was taking prior to going to the hospital. The goal is to ensure that the patient is taking the correct medications, in exactly the right doses and on the right schedule. This can be tricky for a family caregiver with no clinical training, especially when the patient has multiple illnesses or takes numerous medications. For example, many identical prescriptions have different names depending on whether they are brand name or generic, so there's a danger someone may take the same medicine twice. Also, many people are reluctant to discard expensive medications, even when they are expired or have been replaced by other drugs.

Home care nurses reconcile medications on the very first visit. If a patient is not receiving home care, it may be necessary to make a special appointment with a physician in order to reconcile medications.

Be aware of the "red flags" for your family member's specific condition. The VNSNY Transitional Care program includes these red flags in an individualized Action Plan for each patient. The Action Plan specifies warning signs to be aware of so any adverse events can be identified and dealt with before the need for re-hospitalization or a trip to the emergency room. After surgery, for example, a patient's action plan may include reminders to check his or her temperature daily and look for changes in the incision site that might indicate infection. For a patient with chronic heart failure, the recommendation might be to check weight daily, and look for fluid retention that could indicate the need for an adjustment in medications.

It is important that a family member know who to call when any warning signs arise. Typically this would be the doctor or home care nurse, who can intervene early and help you avoid a visit to the emergency room.

Finally, family caregivers should ask hospital staff PRIOR to discharge what accommodations your family member might need at home. Accommodations may include a commode or grab bars for the bathroom, a ramp for the outside stairs, or the movement of furniture and rugs to make way for someone using a wheelchair or crutches. For everyone, prevention of falls is critical. It is always a good idea to do a quick home check once the patient arrives home to make sure there is good lighting throughout the house, no unnecessary clutter or tripping hazards such as skidding rugs or loose wires.

Most people are relieved when they are able to leave the hospital and are eager to return to their routines at home. For the family caregivers of these patients, the first few days after hospital discharge are critical. It is especially important during this vulnerable time to keep an eye out for any warning signs while the patient continues to regain health and strength.

For a helpful hospital discharge checklist and more information on transitioning from hospital to home, visit here. The link also connects you to a great Center for Medicare and Medicaid Service video that provides tips for both patient and caregiver.

1"Rehospitalizations among Patients in the Medicare Fee-for-Service Program," New England Journal of Medicine, Stephen F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H.; Volume 360, pgs 1418-1428, April 2, 2009.

*Names have been changed to protect privacy