Preventing Hospital Readmissions: What Families Need to Know

Hospital readmissions are not just costly — they are dangerous. Each hospitalization carries risks of infection, deconditioning, medication errors, and psychological distress. For older adults, a readmission within 30 days of discharge is associated with significantly worse long-term outcomes.

The good news: most readmissions are preventable. Here is what families can do.

Before your loved one leaves the hospital, make sure you have clear answers to these questions:

• What is the primary diagnosis, and what caused this hospitalization?
• What medications are being prescribed? What are they for, and how should they be taken?
• What activities are restricted during recovery?
• What symptoms should prompt a call to the doctor — or a 911 call?
• When is the follow-up appointment, and with which provider?
• What home health services have been ordered?

If the discharge instructions are unclear, ask to speak with the nurse, discharge planner, or physician before leaving. Do not leave the hospital without understanding the plan.

One of the most common causes of readmission is failure to take prescribed medications. Fill all new prescriptions before or immediately after discharge — not days later. If cost is a barrier, ask the hospital social worker about assistance programs.

Follow-up appointments within 7–14 days of discharge are strongly associated with reduced readmission rates. These visits allow the physician to:

• Review how recovery is progressing
• Identify early warning signs of complications
• Adjust medications if needed
• Answer questions that have come up since discharge

If transportation is a barrier, a home care aide can provide escort services.

Family members and caregivers should know the specific warning signs for their loved one's condition. General red flags include:

• Fever above 101°F
• Increased pain or new pain
• Shortness of breath or difficulty breathing
• Swelling in legs or feet
• Confusion or sudden change in mental status
• Wound that is red, warm, draining, or has an odor
• Inability to keep food or fluids down

When in doubt, call the doctor. Early intervention prevents readmission.

Medication non-adherence is one of the top causes of preventable readmission. Strategies to improve adherence:

• Use a pill organizer filled weekly
• Set phone alarms or use a medication reminder app
• Have a caregiver provide medication reminders and oversight
• Simplify the regimen where possible — ask the doctor if any medications can be consolidated

Physical weakness after hospitalization significantly increases fall risk. During recovery:

• Use assistive devices (walker, cane) as prescribed
• Keep pathways clear and well-lit
• Have someone present during the first days at home
• Follow the physical therapist's activity recommendations

Research consistently shows that professional home health care after hospitalization significantly reduces readmission rates. A skilled home health nurse can:

• Conduct a comprehensive assessment within 24–48 hours of discharge
• Identify early warning signs before they become emergencies
• Manage wounds, medications, and medical equipment
• Communicate directly with the physician's office
• Educate the patient and family about the care plan

Embracing Love Home Care provides post-hospital skilled nursing and home health aide services throughout the Treasure Coast and Palm Beaches. Call 772-266-3099 to arrange care before or after discharge.