The Rules for Recovering at Home for Seniors is Changing

“Going Home Safe”:

The New Blend of Art & Science

How 5 Ingredients Can Make The Critical Difference in 30 Days Post Discharge

By Mark Friedman

If you are navigating the health of a senior hoping to recover at home from a stay at the hospital or acute care, you are probably aware that the deck may be stacked against you. The reality is that, on average, 1 out of 5 seniors return, within 30 days. We know this is one of the most troubling issues crippling our healthcare system in general, and for families, can prove devastating.

As Owner of Senior Helpers Boston and South Shore, I struggle explaining to families why this happens. Where and how do things go so terribly wrong?

First, we know patients leaving a hospital or skilled nursing facility are leaving, in effect, a very “controlled” environment. Virtually everything is being done for them and they have few, if any decisions to make about taking medications, getting physical therapy, or eating. In going home they are returning to an uncontrolled situation, where suddenly they find themselves on their own and in charge of every decision requiring attention.

Second, the discharge process can be chaotic and difficult to customize. Social workers and nurses are over-burdened and have little opportunity to personalize the plan for home. As a result, seniors are often sent home overwhelmed. They may have papers with all the right instructions but too little actual preparation.

We know what can happen in the first day or week at home can sabotage the best of recovery efforts.

A fall.

A missed medication.

Dehydration or simply forgetting to eat. Family members are often at a loss as to how to help. And seniors, many of them proud and independent, are too embarrassed to ask for it. So many of these stories do not have happy endings. There are frantic calls. Panicked visits from adult children.

Or worse, 911 and a trip to the Emergency Room.

A Recovery Program Blending Expertise, Environment, Empowerment, & Engagement

Professionals throughout the healthcare industry agree it is time to change the rules about recovering at home. Simplify the jargon for families and loved ones and empower them with information, tools and processes that enable them to succeed.

We know that non-medical home care support can make an overwhelming impact on readmission risks. But we must do more to help our seniors Go Home Safe. Do more to mitigate the risk of a return to acute care. And more to support their full recovery to wellness.

Going Home Safe must be comprehensive, but not complicated. Any program that is to succeed in preparing and truly guiding the senior’s recovery at home must have five critical ingredients:

1. It must start and be built upon a clear, well-designed, and personalized discharge plan
2. It must be driven by strong post-discharge Nurse Case Management
3. Caregivers must be specially trained for recovery; including diet, medication, mobility
4. All plans should include built-in risk contingencies
5. It must be a collaboration with seniors, families and the immediate system of care providers

In recovery care, the Lead Nurse Case Managers and supporting caregivers have unique skills. They must be able to provide their experience, expertise, and guidance to family members and loved ones in this critical transition.

The Going Home Safe program recently introduced by Senior Helpers Boston and South Shore has been more than two years in development. It guides families prior to discharge and offers a comprehensive suite of programs of care, based on determined risk profiles. We are able to support the home recovery process from 3 to 30 days or provide long term ongoing support.

If a senior or loved one in your life is planning on recovering at home, I invite you to expand your horizons to include these 5 critical new ingredients for success.

Because we have to start somewhere in addressing this broad and incredibly important topic of bringing our seniors home safe, let’s start by making recovery at home safe, manageable, empowering, and engaging.

About Mark Friedman: Mark Friedman is the Owner of Senior Helpers Boston and South Shore. Passionate about seniors and healthcare, the goal of his agency is to set a new standard in home care in Massachusetts. First by delivering an exceptional home care experience in a combination of highly trained and high-touch caregivers. And secondly by becoming a significant connection for elders to resources and services across the more than 100 communities his company serves. He can be reached at MFriedman@SeniorHelpers.com