The Road to Recovery: A Look at Post-Acute Care Options for Seniors

For seniors, hospitalization for an injury or illness means more than being out of commission for a couple of weeks. Because of age-related vulnerabilities, including slowed healing speed and preexisting chronic medical conditions, their post-acute care can be long, taxing, and laden with roadblocks and setbacks. In fact, following a hospitalization, nearly one in five Medicare patients (about 2.6 million older adults) return to the hospital within a month of discharge, according to data from the Centers for Medicare and Medicaid Services (CMS).

Funded by a grant from the National Institutes of Health, the three-year study that yielded this data looked at post-hospital emergency care and hospitalizations among seniors who had one or more of six common operations: angioplasty or other minimally invasive heart procedures, coronary artery bypass, hip fracture repair, elective abdominal aortic aneurysm repair, back surgery, and colectomy. Visits to the emergency room after surgery were not only common — with 17 percent of these senior patients making one emergency visit within 30 days of leaving the hospital, and more than four percent making two or more visits — but were also predictors of another hospital stay. More than half of the older adults who sought this emergency care ended up back in a hospital bed. In 2012, the CMS took action to remedy this problem by financially penalizing hospitals with high readmissions rates in order to motivate them to work harder to prevent avoidable cases.

While some cases of post-discharge complications are unavoidable, several factors play key roles in ensuring that a senior receives the proper post-acute care and rehabilitation after a hospital stay and gets back to her optimum level of functioning. Strong continuity of care between healthcare providers and a full understanding of the post-discharge treatment plan on a senior’s part are among the most important. Here’s a closer look at the levels of post-acute care available to seniors, and the treatments and services they provide to ensure that patients receive fuller recoveries.

Short-Term Home Care

Before an older adult patient is discharged from the hospital, a discharge planner, usually a registered nurse or clinical social worker, works with the doctor, patient, and family to determine her post-acute care plan. If she is deemed stable enough to return home but still needs rehabilitation services and intermittent skilled nursing check-ins for a period of time, home healthcare provided by a certified home health agency is recommended. Short-term home care provides a variety of services within the patient’s home, which might include physical, occupational, and speech-language services; visiting nurse services that include help withmedication management; assistance from a home health aide; nutrition services for those who qualify; and even medical social services such as counseling to cope with emotional concerns related to the senior’s illness.

Frequently, and despite healthcare providers’ best efforts, seniors leave the hospital without knowing fully what they should do when they arrive home, with whom they should follow up, or where to direct questions about the various aspects of their care plan. Visiting nurses help to bridge this gap. During their visits, they may administer medications, obtain prescription refills, and provide guidance to the senior regarding dosage levels, timing schedules, and whether to eat with a medication. They may also address any questions or adverse side effects she may be having, which can remove barriers to the senior’s adherence to her medication regimen.

For more on how to help your patients with medication adherence, read the e-book “Engaging Your Patients in Effective Health Management.”

A home care dietitian may also be assigned to the older adult if she has specialized nutritional needs following her hospitalization and requires a nutritional assessment, such as with diabetes and chronic pulmonary hypertension.

“I do full assessments, ask them how much they are eating and if their appetites have changed,” says Therese Franzese, MS, RD, CBE, CDN, clinical nutrition manager for Hebrew Hospital Home Care. “Often it does change from anesthesia if they’ve had surgery, and they may have developed some sort of GI discomfort from medications — so I make sure they get plenty of extra fluids and fiber.” During that initial assessment, Franzese will also determine whether a patient is nutritionally high risk or malnourished, and from there decide how often she needs follow-up visits. A high-risk senior will receive a dietetic visit every 90 days. At these visits, Franzese addresses everything from barriers to eating, such as chewing difficulties or appetite changes, to proper compliance with dietary restrictions.

Another important feature of short-term home care is assistance from home health aides, who may stay with a senior for up to four hours a day and perform tasks around the house that the senior cannot carry out herself. Many seniors who are discharged from the hospital are well enough not to need 24-hour attention in a skilled nursing center, but they may be unable fully perform the activities of daily living. Home aides provide much-needed care in the early days of recovery, especially when family members are not available to perform these tasks. They can assist with bathing, dressing and grooming, eating, and using the bathroom.

“Home care is for seniors who had some kind of episode that makes them homebound, and though they can continue to live in their own homes, they need help,” says Beth Goldstein, CEO of Bethel Homes and Services, a nonprofit organization that offers the full continuum of senior care. Home aides can also conduct errands for the senior, go grocery shopping, and perform light housekeeping and meal preparation. For seniors who are living alone or do not have family nearby, aides can accompany them to follow-up medical visits. However, it is important to remind your senior patient that home aides do not have full medical training; any medical questions that come up should be directed to their doctor or nurse.

Older adults under Medicare are covered for home health services if their doctors certify they are medically necessary, and Medicare initially pays them at 100 percent. Seniors in independent or assisted living centers are also eligible to receive this care. In addition, the home health agencies that provide these services can provide any durable medical equipment that is necessary, such as a walker or cane, for which Medicare usually pays 80 percent of the Medicare-approved amount.

If a senior still requires rehabilitation services or medical check-ins at the end of the Medicare-approved amount of visits and cannot leave her home without considerable difficulty, her healthcare provider may reorder these services every 60 days; however, these services may not be fully covered under Medicare after the first 20 days. After 100 days, Medicare stops covering these services, so the senior would have to pay privately or apply for Medicaid if she is eligible.

Adult Day Care Centers

Adult day care is a great option for seniors who live with caregivers but who cannot be safely left alone at home during the day. These centers allow older adults to receive needed functional assistance such as personal care and meals, along with medication management from licensed nurses. Seniors also benefit from the social environment and activities, and some adult day care centers offer transportation. Your senior patient or his caregiver can locate an adult day center in their area by calling the Eldercare Locator, a public service of the Administration on Aging, at 1-800-677-1116.

Skilled Nursing Facilities

More commonly called nursing homes, skilled nursing facilities provide the next level of post-acute care, offering both short-term and long-term stay options. They provide around-the-clock skilled nursing care, including dispensing and monitoring intravenous medications, and therapy services to seniors who no longer need acute, hospital-level care but who cannot manage living at home — whether temporarily or long term. Licensed doctors are on staff and can usually be reached at all times.

Short-term care at a skilled nursing facility offers rehabilitation services that focus on improving or restoring functional independence for seniors, with the goal of preparing them to live independently again. These facilities also provide social and educational activities to boost social stimulation and positive interaction among older adults. This not only helps ward off depression and isolation — two predictors of decline in seniors — but also aids in the healing process. “Through nursing, dietary help, social work, rehabilitation therapy, and therapeutic recreation, we aim to help seniors get back the level of independence they need to function at home,” says Geraldine Albers, licensed nursing home administrator and assistant administrator at Carillon Nursing Home.

Long-term care at a skilled nursing facility is a permanent move for seniors who are no longer able to manage their activities of daily living after a hospitalization or as a result of an illness. “[These seniors] are in a place where they can’t get to the doctor or out for their medical needs, and their families can’t do it or are no longer able to give them all the care they need,” says Albers. While many seniors view relocation to a nursing home as a permanent loss of independence, it provides needed round-the-clock medical service and on-site personal care services that would be impossible for some seniors to otherwise receive.

“The stigma of a nursing home shouldn’t be the stigma of a nursing home,” says Albers. “If a senior cannot go out to get a haircut or run an errand without it being a traumatic situation, long-term care is the way to go. We keep seniors participating in activities with meaning, we bring in lectures, we have yoga programs when appropriate and sensory activities for residents who need cognitive stimulation.”

Long-Term Home Care

Some older adults prefer the comforts of long-term home care. Such care is available for seniors who would otherwise need to be in a skilled nursing facility if they didn’t have home care. While not covered under Medicare, Medicaid fully covers this service. Long-term home care is more intensive than short-term care, and equivalent to the kind of treatment a senior could receive from a long-term skilled nursing facility.

A medical alert device can give a senior in home care extra security and peace of mind. If you know a caregiver or a senior receiving care who would benefit from information about medical alert devices, refer your patients to Philips Lifeline.

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