Preventing Re-hospitalization

Posted on 5 January, 2014 at 14:45

Life Journeys, LLC. Registered Nurse Geriatric Care Coordination

Changing the end of the story…

As the aging person experiences episodes of illness or decline, returning to their prior level of functioning becomes increasingly difficult, making loss of independence a continual threat. When our loved ones experience changes in their health that affect their abilities to continue to remain safe and independent, they need a better understanding of the choices they are facing, and how to access the level of care they may now require.

Patient care has come around full circle, from the long hospitalizations of many years ago, to acute short stays focused on getting the patient stabilized quickly, and then transitioning them to a lower level of care, all in the name of saving healthcare costs and maximizing profit.

With these rapid transitions, patients are often moved through the healthcare delivery system without clearly understanding the choices being offered to them. Many times a person’s preferred choice is to continue to living in the familiarity of their own home or the home of their grown children for as long as possible. However, returning home may not be the best option unless there is a capable family member or friend to help plan, coordinate, and follow through with making sure their care needs are truly being met. Unfortunately, many families don’t have a person capable of helping to meet these changing needs.

Any changes in health can trigger a further cascade of problems that need to be addressed quickly while they might still be safely managed, and re-hospitalization can possibly be avoided. By utilizing RN Geriatric Care Coordination to help make a plan, put services in place, and work directly with the client and their family to oversee ongoing care needs. If changes in health occur, they can be managed quickly and more effectively. With improved response to changes in condition, our patients and clients will have the best chance of maintaining their highest level of independent functioning. Other priorities include conserving their assets and resources, preventing re-hospitalization, and improving their chances for long term overall optimum health.

By seeing our patients in their own environment, we can observe them in ways that are not always apparent during an office visit or a typical hospitalization. The family dynamics, as well as their individual lifestyle and health habits are more easily recognized, allowing us to focus our teaching to more specific needs and helping to resolve problems before they become more difficult to manage.

Helping our patients and clients find acceptable choices for changing unhealthy lifestyles is of key importance, making compliance with living healthier and remaining safe and independent at home a more realistic option. The reality of cutting the healthcare costs of this nation depends on our ability to help the aging population find ways to make these healthier lifestyle habits do-able at their level of ability.

Utilizing the services of a Geriatric Care Coordinator to work with families to build a structured plan of care can make these challenges seem more manageable and less overwhelming A viable option for many families might be having a family member or friend who can help, at least on a limited basis, if given directions and a coordinated plan that respects the family’s resources, abilities, strengths, and needs. A coordinated plan that includes additional support from professional medical or non-medical home healthcare agencies can make an overwhelming situation managable.

Ultimately, by remaining safe at home with care needs met, assets and resources can be conserved for long term care needs in the future. We will also be delaying facility care before it is needed, and minimizing or avoiding the need for endowments and long years of government subsidized facility care.

There are times when caring for loved ones at home is not realistic or safe. Sometimes we are even trying to care for our loved ones from another city or state. Consequently, more customized options are being made available for our patients and aging parents. Understanding all of these options can be challenging for healthcare providers as well as the seniors and their families themselves. Utilizing RN Care Coordination also helps families make these difficult life changing decisions by helping to make their transitions smoother and less traumatic.

Supported family involvement, as well as a person’s level of being able to care for their own needs as they decline physically and/or mentally, contributes to determining the direction and level of care needed. Medicare or insurance reimbursement for needed healthcare services can also affect the type care a person receives, and for what period of time.

Our Medicare system managed by CMS (Centers for Medicare & Medicaid Services) is more often than not, the major determining factor in services being received. What does the future hold for a healthcare system that is facing unfathomable changes? The only chance of survival will be cost containment, resource management, and the patient themselves doing their part in adopting healthier lifestyle habits. If individuals do not make those changes, they not only personally suffer the consequences in ill health, but also must pay higher health insurance premiums along with others in their network.

Some of the questions we must ask ourselves as diligent healthcare providers…

• Where will our patients ultimately end up?

• Will they thrive at home?

• Or will they fail because of lack of funds, or lack of coordination of the services they needed to manage their care needs within the safe environment of their own home?

• Will they continue a cycle of returning to the hospital where they started because their care needs are not being adequately met?

• Will the hospitals continue to take them in again and again at the risk of no Medicare insurance reimbursement?

• Will they move on in the continuum of care to a different or higher level of care in the system?

• Will it be where their needs are being appropriately met?

• What does the future hold for supporting our own changing healthcare needs as we ourselves experience aging?


As true patient advocates, it is our responsibility to understand the healthcare choices available to our patients and clients, and to help them access the appropriate level of care within a system that offers choices that are usually confusing and overwhelming, especially at a time when they are likely experiencing life changing circumstances and are vulnerable.

Utilizing RN Care Coordination as part of Care Management teams just makes sense when it comes to quality care expectations and outcomes. Working together for our patients teaches them to maintain accountability for living healthier, helps them to maintain their autonomy longer, and helps to keep runaway healthcare costs more manageable for all of us.


For a free consultation please contact us,


Life Journeys, LLC,

Registered Nurse Geriatric Care Coordination

515-554-5489 [email protected]


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