Subscribe
Share
Share
Embed
Welcome to Healthcare Redefined: Advocating for Aging Adults and Their Families, where we empower families to navigate the complexities of aging and healthcare. Presented by Your Nurse Advocate Consulting, we share real stories, expert advice, and practical tools to help you and your loved ones confidently navigate aging with dignity.
We explore topics like creating collaborative care plans, demystifying Medicare, handling healthcare crises, and preparing for the future. Join us as we transform uncertainty into understanding.
Pam Dunwald: [00:00:00] Hi, welcome to Healthcare Redefined: Advocating for Aging Adults and Their Family. This is our episode number four, Avoiding Hospitalization Readmissions. Hi, I'm Pam Dunwald.
Linda Kritikos: [00:00:11] Hi. And I'm Linda Kritikos. We're both registered nurses, board-certified patient advocates, and owners and operators of Your Nurse Advocate Consulting. And we're really glad you're joining us. Welcome back to people who have been with us for the first three episodes. And also welcome to any new listeners.
Pam Dunwald: [00:00:30] You know, today we're talking about a topic that affects so many families, and that's hospital readmissions. And what exactly is a hospital readmission? That is when you're discharged from the hospital, and you're re-admitted to the hospital within 30 days that you have been discharged. So if you've ever had a loved one come home from the hospital only to end up back there within weeks, you know how stressful and discouraging this can be.
Linda Kritikos: [00:00:55] It can be extremely frustrating and discouraging. And sometimes it doesn't even take 30 days, does it? I mean, sometimes. I mean, it can be 72 hours. Or the next day. So hospital readmissions aren't just frustrating. They can be very, very risky, costly, and often very preventable. That's why advocacy, such as what Pam and I do, plays an important and really crucial role during and after a hospital stay.
Pam Dunwald: [00:01:22] So let's break down some of the most common reasons older adults end up back in the hospital. Number one: confusing or incomplete discharge instructions. Sometimes the patient, the aging adult, is the only one receiving those discharge instructions. There's not a family member present or another person, and sometimes they just don't understand all of it. Number two: medication errors or missed prescriptions. We're going to talk a little bit about that when I share a story in a few minutes. Lack of follow-up appointments. Sometimes you're discharged on a Sunday, you can't reach the clinic to schedule appointments, so that's left for someone to take care of during the next work week or the next work day. So that becomes an issue. Number four: unaddressed symptoms or complications at home. And the last one: poor communication between the hospital, primary care, and any specialists.
Linda Kritikos: [00:02:12] Oh, how very true. That has been a problem for a long time. And you and I both have experienced these things. So these gaps can turn a successful discharge or what should be a successful discharge into a revolving door. But a lot of times, with the right support, you know, many readmissions then can be avoided through proper, you know, discharge planning and advocacy. You know, this is where a nurse advocate can step in. You know, we help families to understand and clarify discharge instructions. We make sure that all medications are correct and that their prescriptions are filled. We help schedule and track follow-up appointments. We can help you recognize warning signs and when to know to call the doctor. And lastly, we can bridge those, you know, that communication between all members of your healthcare team and the family. So, you know, we're really here for you to help ask the right questions. We've been in healthcare for a long time, so we know some of the questions that should be asked that a lot of people don't. We catch missing details. We make sure nothing falls through the cracks. Think about if you were an elderly woman or an elderly man living alone, and you went into the hospital or the doctor's office because you didn't feel good, and they saw you for your appointment, and they handed you a visit summary and 3 or 4 prescriptions and said, Here you go. And you also have a diagnosis of mild dementia. Are you going to follow through? Who do you need to help you? Who will help you?
Pam Dunwald: [00:03:52] You know, that's a really good point. We have a lot of aging adults that are what they call solo agers, and they're living home alone, and they don't have any resources, or they don't have family close by to help them manage. And another good example of how an advocate can help. So I'm going to share a quick story. You know, I worked many, many years in the hospital, and people don't, again, Linda mentioned it before in another episode, where people they just don't know what they don't know. And so I just want to take just a minute to educate you on some of the things that can go wrong in a discharge process that we think are just automatic. So, for example, when someone's being discharged to a nursing home, the nursing home wants the doctor's discharge summary as soon as possible. Those are their orders so that they can get, on their end, the nursing home can get medications ordered, they can make sure they have the right supplies, they can make sure that they're ready to receive this patient, you know, after their discharge from the hospital. Okay. So the doctor does the discharge summary, the social worker, the discharge planner, the case manager, whoever is working on that process sends that discharge summary over to the nursing home. Okay. We think, okay, we're staying ahead of it. We're giving them enough time. 15 minutes before discharge, the pharmacy says to the doctor, oh, you know, we had to change this dose. We had to change this medication. We just got culture results back, we have to change the antibiotic. This, you know, this one we want, it will work better. So now the doctor has to go in, update the discharge summary, make all that. Well it's already been printed and sent to the nursing home.
Pam Dunwald: [00:05:26] Now, if someone is not manually catching the fact that there was a change made at the last minute as the patient's walking out the door, the nursing home isn't going to get that correct medication list. And there, boom, opportunity number one for medication error because the nursing home is now not having the correct medication. So these are the type of things that can fall through the cracks. And how these mistakes, no one's making any mistakes intentionally, everybody has everyone's best interest at heart. They're doing the best they can, you know, we just want to reiterate it. It's really no one's fault. It's a gap, it's a crack in the system, and in the process, and so that's where we can come in. We're, you know, we're following up. We'll know what that new medication was because we're asking those questions. We're present so we can make sure that all the dots are connected and everybody knows what's supposed to be done.
Linda Kritikos: [00:06:23] Yeah, that could have some really, really serious consequences. I mean, did you see a lot of those things when you were working in the hospital system?
Pam Dunwald: [00:06:32] Absolutely. Real quickly, we had a patient that was discharged from the hospital that was supposed to be started on a blood thinner. It was one of the newer ones. It was very expensive. The wife didn't come up to hear the discharge instructions. She had us bring down the patient to the door. She picked him up there in front of the hospital, went to the pharmacy, found out how much co-pay that medication was, and she chose not to pick up the prescription. Nobody knew until days later that he was not taking the blood thinner, that he was sent home with from the hospital.
Linda Kritikos: [00:07:04] So. And she probably didn't understand the consequences of that decision. So education is a really important part of that discharge planning. That's where advocacy can come in to help with that.
Pam Dunwald: [00:07:16] Absolutely. And one of the things, as an advocate with our knowledge of the different new anticoagulants, one of the questions that I would have had, had I been an advocate for that patient and had been involved, you know, having in the know, is to look at their insurance formulary, which one of those, usually they'll cover one or the other, like an Eliquis or Xarelto. Those are the new blood thinners. Usually, they'll cover one or the other; sometimes they'll cover both. But I would have looked at that pharmacy, or that insurance formulary to see which one might have been covered under their insurance, and this could have been checked ahead of time to make sure that they wouldn't have had that sticker shock when they went to pick up that medication.
Linda Kritikos: [00:07:56] Yeah. Another situation would be someone, as I had a recent client, and you know this client, that had multiple ER visits all for the same thing because what was happening was the individual had dementia, but it wasn't really - because they're so busy in the E.D., they're so busy, and again, nothing is intentional - but didn't realize that the patient was activated and had an activated healthcare power of attorney, but was asking the patient the questions in regards to what was going on with them.
Pam Dunwald: [00:08:32] Yeah. Linda, could you just explain to our audience, just what does that mean when it's activated? Sometimes they're not, you know, that's not real clear to people.
Linda Kritikos: [00:08:40] What that means is that when an individual can no longer make good, rational decisions regarding caring for themselves or finances or in medical decisions, a lot of times they have an activation is done. It takes two physicians or two healthcare providers to sign off, they do different types of testing to make sure the cognition is or is not there. They ask certain questions, they do certain types of testing, and two physicians or two practitioners would sign a form or a document that says that this patient is really not able to, at this point in life, to make good decisions in regards to their finances or their healthcare. And those decisions then go to the person that they have chosen as their power of attorney for healthcare, or a durable power of attorney for healthcare and finances. So when they're activated, they should be turning to that power of attorney for those decisions in regards to healthcare and getting a history and getting medications. But sometimes in the busyness of our roles, we don't always look for that. And that can cause a lot of issues, as it did with this individual, because no one was notified, and he kept returning. He had four ER visits in a period of two weeks, until finally someone picked up the phone and called the healthcare power of attorney and said, You know, this individual has been seen here, what's going on? They said, Well, I was never notified. Why wasn't I notified? It's right on there that he's activated. Oh, we didn't know that. So this individual had four ER visits because of communication. Or lack thereof, which could have been avoided if they had contacted the healthcare power of attorney, who would have then contacted me as the advocate, and I could have coordinated a lot of those issues and possibly resolved and prevented some of those readmissions.
Pam Dunwald: [00:10:46] You know, and just a side note, when we're talking about activating power of attorneys, we just want to know, this is, you know, with the two providers, this is the process here in Wisconsin. Every state might be a little different. So you want to check with your state regulations on what it takes to activate a healthcare power of attorney or advanced directive. So just a little side note.
Linda Kritikos: [00:11:07] Yeah, that's very important because you're right. State to state, it could be very different. And the forms that they use could also be very different. And the documents that they need for it could also be very different. So, in saying that, research shows that, you know, having a patient advocate involved during these transitions of care is, not just by the stories we told, but statistics are saying this, that the care that we provide can reduce hospital admissions by 30%. We have said this before in our previous episodes, that 30% is quite a few readmission preventable causes. So families report greater peace of mind and improved medication safety, and along with better consequences in clinical outcomes when they're using a healthcare advocate.
Pam Dunwald: [00:11:54] You know, a 2024 report from the Patient Advocate Foundation found that patients with advocate support had fewer complications and higher satisfaction with their recovery at home.
Linda Kritikos: [00:12:05] So, we here at Your Nurse Advocate Consulting, we specialize in making sure that your family and you can navigate these critical transitions. Our independent nurse-led approach means your loved one gets the personal hands-on support every step of the way.
Pam Dunwald: [00:12:24] You know, and if you're preparing for a hospital discharge or just want to be proactive, reach out for a free 30-minute consult. It can't hurt. We can help. We'll help you build a plan that keeps your loved ones safe and supported at home.
Linda Kritikos: [00:12:37] So thank you for listening to Healthcare Redefined. If you found this episode helpful, please subscribe, share it with a friend, leave us a review, and again, if there's input that you want to give us in regards to future episodes, send us information, and we'll be more than happy to research it and then put it out on one of our podcasts.
Pam Dunwald: [00:12:57] You know, and remember, you don't have to face the healthcare system alone. Advocacy can make the difference between a smooth recovery and another trip to the hospital. You know, we're going to include our free resource in the show notes, and that's transitions in care. And it's going to give you some of those talking points that we have, things that can help you prepare for a discharge, whether it's a transition from home to the doctor's office, from the hospital to the nursing home, or from the hospital home. So this will be available again in the show notes.
Linda Kritikos: [00:13:25] Thanks so much, and have a great day.
Pam Dunwald: [00:13:27] Take care.
Resources: Free Guide and Checklist: "Caregiver Checklist for Successful Transitions in Care" Avoiding errors when leaving one level of healthcare to another and then home. Example going to the hospital then to a nursing home and back home. Addressing the gaps in care and how mistakes can happen.
https://yournurseadvocate.yournurseadvocateconsulting.com/aging-adults-safe-home-safety-checklist.html