I have often asked myself how many elderly and frail sitting in wheelchairs in the hospital lobbies waiting for transportation have the full support they need at home.

The fragmentation of care is particularly evident in patient handoffs – whether they occur within the walls of the hospital, or during a transfer to another department or facility – making them prone to errors….  Joint commission analysis found that 70% of sentinel events were caused by communication breakdown; half of those occurred during handoffs. Another consequence is that patient and their families often feel “lost” in the system….” (PHSA strategic plan 2010-2013)

This quote speaks to movement within the health care system but does not mention those leaving the institutional setting to go home.  I have heard many stories where seniors returned to hospital within weeks of their original stay.  This is a common occurrence and not a fault of anyone specifically but a failure on the part of the system.  If the system is supporting aging in place as is evidenced with the provincial support for  Better at Home Program  funded by the provincial government and managed by United Way; we also need to fill the transition gaps to support the well-being of seniors in their later years living independently after hospital stays.

The patient is no longer the responsibility of the hospital once they leave the hospital however the hospitals’ Care Management Leaders responsibilities include making arrangements with the likes of health authority or private care or family  to support the patient in being safe at home.

Caring for the frail elderly is a costly and complex task. Return visits to the hospital with overnight stays are costing hospitals over  $1000 per person/bed.  I acknowledge the good care given, as well as the struggles the hospitals have with managing hospital- to- home planning for patients.

These return visits are often due to going home with incorrect or no support in place, leading to injury and decline in health caused by lack of fluids, poor eating or taking medications incorrectly leading to delirium, falls, depression etc.  The reason for this is it’s impossible for the hospital to anticipate all possible barriers or needs that may surround an individual in their home; be it physical, social or emotional.  Furthermore the patient is often unaware of their own limitations and unable to point out or ask the questions to put the correct supports in place.

A continuum of care or “full cycle of care” (PHSA Strategic Plan 2010-2013) as the objective, should include transitioning hospital to home using a monitor and liaison as well as a management  and support strategy to reduce costly return visits to the hospital after discharge.

Care Management Leaders already work collaboratively in teams, meeting with those who know the patient personally when available and with the right documentation in place.  However when there is little or no understanding by the family of the system and options available; or where there is no family, friend or caregiver, a private seniors advocate who knows the patient plays an important role working with the CML to ensure the patient has all the supports required for a smooth recovery when they get home as in Betty’s case (link). Working together will reduce the number of unnecessary costly returns to hospital and ensure seniors’ wellbeing.

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Patient/Person Centered Care – Seamless Transitions Hospital to Home
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