After a hospital stay, many seniors on Medicare will go to a nursing facility to rehabilitate before going home. But a new study from Duke University, UNC Chapel Hill and the Carolinas Center for Medical Excellence shows many of them return to the hospital before long.
Mark Toles teaches at UNC's Nursing school and is a co-author of the report. He said nursing homes often provide good care, but the transition back home can be difficult.
“Plans of care have changed along the way. Medications have changed along the way. Instructions have accumulated a long the way,” Toles explained. “And it's very difficult for patients and caregivers to remember everything, and to coordinate everything.”
Toles says about 20 percent of those clients go back to the hospital within 30 days.
“We also found that within 90 days of the time patients get back home, almost 40 percent of them needed to go back to the hospital for an E-D visit or for an admission,” said Toles. “This indicated to us that something needs to be done for that group of patients to make it safer for them when they get home from the nursing home.”
Toles said he's now shifting his attention to studying how nursing homes can work with clients and caregivers to make a smoother transition home.