Care Management: Making The Difference in Avoidable and Unavoidable Hospital Readmissions

A hospital visit is emotionally and physically exhausting. What is just as stressful? The discharge process, follow up care, and the looming possibility of being readmitted to the hospital. Many situations can lead to a readmission including but not limited to: not enough time to implement a health care team resulting in lack of post-discharge support, insufficient follow up, medication related issues, complications following procedures, infections, and falls.


Often senior readmissions take place from the lack of understanding why they were in the hospital to start, what they need to do once they return home to foster a safe recovery, and why follow up appointments and proper medication management are important. To fully understand your loved one’s care plan and to help reduce readmissions, choose a home care agency that offers Care Management.

Although post-discharge can be a stressful situation to face, Home Care Partners is here to offer support with our Care Management Team.

Care Management is an ongoing collaborative approach to managing conditions and injuries that pose a risk of rehospitalization that many other agencies fail to review. Our Care Management Team is in close coordination with others in a client’s health care continuum to fully understand the situation at hand, which can include: home health providers, therapy teams, hospice, primary care doctors, pharmacist, and inpatient and outpatient coordinators. This allows clear communication between all health professionals for the client’s benefit. Our caregivers are then able to provide the recommended care for a client to avoid a readmission, including providing medication reminders to reduce medication errors, follow-up appointments, and at-home physical therapy exercises.


Care Management also assists in reducing avoidable readmissions and recognizing unavoidable readmissions early on through technology. Our Caregivers chart electronic care notes and documentation, which gives our Care Managers the ability to provide real time proactive healthcare when vitals are out of range or a decline in health occurs. Our Care Managers follow up with patients to pinpoint any challenges and determine support to overcome these obstacles. If it is decided a client needs to be readmitted to the hospital, we are able to see it early; preventing a larger health decline. This aspect of being real time is such an important factor in providing care. If daily care notes are written out on paper and read by a Care Management team once a month or once a quarter in a client’s home, real time care is not taking place resulting in overlooked health concerns progressing into a large health decline. Caring for someone with a chronic condition requires real time oversight and the ability to coordinate to provide health interventions through care from a truly interdisciplinary care team.


Home Care Partners services combined with care management extends the support we are able to offer to clients. Contact Us today at 402-780-1211 to discuss your loved ones current situation, whether they need long term care or restorative support after a hospital stay, and to create a care plan.


Learn More About Care Management Read Our Blog on Assisted Living at Home

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