Sidestepping Hospital Readmissions

Research shows that 15% of older adults who spent time in a hospital will be readmitted within a month of their discharge. Why would a person who has just been discharged from the hospital need to go back? We posed this question to Dawn Usher, an elder care coordinator at Elder Law of Middle Tennessee, a Life Care Planning Law Firm in Lebanon, Tennessee. Dawn sees the following situations as the most common causes of hospital readmission.

Post-Acute Home Care

Failure to follow discharge instructions is one of the biggest reasons for readmission. “The single most important thing a family can do is to make sure that there's somebody there with the elder, whether it's a family member or someone you pay,” Dawn advises. “It’s important to have someone with them to make sure that follow-up and discharge instructions are followed correctly.” Fortunately, there are options for family caregivers whose work or family obligations make it impossible for them to stay with the elderly loved one. “Many people don’t realize that there are companies who can come into the elder’s home, provide medication reminders, assist with transportation to follow-up appointments, and more.”

Medication Errors

This is an often-overlooked source of readmissions. “Older adults may be admitted to the hospital with one list of medications, but the list may not be updated to reflect prescriptions added during their stay,” Dawn says. “The post-discharge medication list may be missing items and those errors may not be caught right away.” What can caregivers do? Dawn advises carefully comparing medications lists issued at discharge with the hospital’s records.


The risk of a fall-related injury increases when older adults are in a weakened state following a hospital stay. Self-care can become a challenge, especially if a senior’s mobility is compromised after discharge. For Dawn, this is where having a caregiver in the home can be especially valuable. “The presence of a caregiver to help the elder with things like dressing, bathing, shopping, and getting around the house can go a long way toward preventing falls,” Dawn advises.

Poor Care After Discharge

Follow-up care plays a key role in preventing readmission. Unfortunately, many seniors, especially Medicare patients, fail to follow up with their primary care doctor following discharge. Others make—and then ignore—follow-up appointments. Dawn suggests three ways to improve post-discharge care coordination. “First, try to make sure that follow-up appointments with primary care providers are scheduled before discharge,” she advises. “Second, arrange transportation to and from appointments, and third, provide reminders as the appointment time approaches.”

Lack of Planning

For many family caregivers, caring for elderly loved ones means reacting to one crisis after another, which can set the stage for hospital readmission. That’s where elder care coordinators working in Life Care Planning Law Firms can be so valuable. “When I’m working with a client who was just released from the hospital, I am creating the space for family caregivers to be more proactive,” notes Dawn.

Her support starts with a home assessment to identify risk factors. She then develops a plan to make sure that the elder gets the right care during those critical first weeks after discharge, drawing on her vast knowledge of available resources and care providers. Sometimes, her support comes in the form of simple reassurance. “Everyone wants to make sure that their loved one is getting the right care,” Dawn adds. “I just point them in the right direction.”