Hospital to Home: How to Prevent Rehospitalization

Dear Jane:

My uncle, who I am a guardian for, is in the hospital. In addition to having surgery to repair his broken leg, he has Alzheimer’s disease. He has been living with my wife and me for about a year now.

We were having a tough time managing his care before the fall that caused his leg fracture. So we are more than a little concerned about how we will help him safely transition back home.

Do you have any recommendations for us? We would really appreciate any advice.

Sincerely,

Rob

Safely Transitioning from Hospital to Home

Dear Rob:

Alzheimer’s can be a very difficult disease for families to safely manage at home so I’m not surprised to hear your concern. And people with Alzheimer’s have difficulty adjusting to a new environment like the hospital. I’m sure you and your uncle have been experiencing some tough days.

My first question is: Will your uncle be transferring to a skilled nursing and rehabilitation center to continue his recovery? If his physician hasn’t recommended it yet, you should ask. If your uncle had a 3-night stay in the hospital and meets the criteria for admission, a skilled nursing and rehab center can be a safe place for him to stay and continue his therapy.

The staff at a rehab center is accustomed to working with people who have Alzheimer’s. Caregivers understand how to communicate with older adults who have difficulty following directions and communicating because of their disease.

My other advice is to make sure you are comfortable with a few other important factors as he transitions from the hospital or rehab center to your home:

  • Will your uncle need follow-up appointments with any of the physicians who treated him in the hospital or at the rehab center? Make certain you have the contact information you need to schedule those before he is discharged.

  • Has his medication schedule changed? This not only includes making sure you know how to manage his new prescriptions, but also understanding if any old ones need to be changed or discontinued.

  • Diet and nutrition play an important role in the healing process. Ask his physician or the discharge planner at the hospital to clarify what type of diet he should follow while he is recovering.

  • Finally, ask for a timeline on what to expect throughout his recovery. What milestones do they anticipate? And what are the early warning signs that might indicate a problem the doctor should be informed of, such as a fever that might be a sign of an infection? Feeling as if you are educated on what a typical recovery looks like can help you feel more confident caring for your uncle.

I hope this helps, Rob! Good luck to you and your family.

Kind Regards,

Jane Solt, RN Director of Nursing