We hear a lot about the cost to Medicare of seniors returning to the hospital within days of being released. Here in Moscow, we have a transitional care team—staff from the hospital’s discharge department and representatives from the local care facilities and senior care agencies—which meets to talk about how we can work together to help our seniors get the help they need at home after a hospital stay.
At a recent meeting, we looked at individual case histories of seniors who had been recently discharged from the hospital and directed to enlist homecare services. Our hospital discharge planner confirmed that medical staff were consistently evaluating the patient’s need for assistance at home, and that the discharge team were also consistently educating the patient and any family members present at discharge about whether home health care was indicated.
Some of the case histories showed that the senior had gone from a hospital stay or emergency room visit to a stay in a care facility. Representatives from our local care facilities also confirmed that they meet with the senior and any family members available at the time a resident returns home, and recommend homecare services when needed.
In fact, here in Moscow, not only are our local hospital and care facilities evaluating and making referrals to homecare when it is needed, but they also provide seniors with a special directory of all agencies and providers of the homecare and senior services available in our area. And, we are more fortunate than many rural areas – even though we are not a large population center, we have a diverse array of services for seniors.
Why, then, do we have such a problem with seniors not making use of the services available to help them stay safer at home?
I think the problem is a sociological one, not administrative. I think our local hospital, clinics, and care facilities are doing a great job of acquainting their patients with services that will help them succeed when back at home on their own. I think the problem is a generational one, one to be solved on a sociological level.
When I work with people who are in the seventies, eighties, and nineties, I am invariably struck by their fierce independence and desire to manage on their own. I think their determination to be responsible for themselves comes from their earlier life experiences during the Great Depression. One of my clients told me that, as a boy, he never asked for seconds at a meal because he knew his mother was already going without. Another client told me that her feet have hurt her all her life and that she suspects it is because she and her younger sister shared a single pair of shoes one year. I imagine walking barefoot to school might have caused her feet injury, but more likely she was forcing her feet into shoes that were far too small for her.
And, when dementia is part of the picture, anosognosia often comes into play. Someone who is unaware of his or her disabilities or impairments will neither seek nor accept help. I have seen people unaware that they need to lean on a walker in order to stand, not just utilizing bad judgment about whether to use it.
In order to lower the expense of seniors being discharged to their homes and then becoming re-injured or sicker once there, I think we need to consider the sense of independence our elders learned by living through the Great Depression. That experience cannot help but contribute to their resistance to care, as does anosognosia when it is present.
For further discussion on the national problem of re-admits, see: