Why Hospital-to-Home Transitions Matter: A Critical Moment for Patients, Families, and Employers by Zack Demopoulos
One of the hardest parts of being a long-distance caregiver like I am for my mother, who is over 600 miles away, is hospitalizations. My mom is 96 years old, hard of hearing (even with hearing aids), and English is her second language. For these reasons and many others, she always needs an advocate with her when health issues arise. Without proper advocacy, the risk of miscommunications, misdiagnosis, overtreatment, delayed discharge, and less-than-adequate care increases.
A Moment in My Care Journey
As we start into a new year of caregiving, I thought I would share a critical moment from my personal care journey. I already mentioned that I am a long-distance caregiver, right? Well, a week before Christmas, my mother was admitted to the hospital for atrial fibrillation, congestive heart failure, dehydration, and UTI. With the pending holidays, a growing shortage of staff, seasonal flu, and other viral episodes, getting someone on the phone to get status updates or trying to return a call to a physician who left me a message while I was in a meeting was extremely difficult.
Even though I was given a patient portal app for information access, my questions went unanswered. After four days of hospitalization and no progress, I decided I needed to get on a plane and go to my mom. My goal was to make sure that her medical needs were thoroughly addressed and get her safely back to her nursing facility, a place that was home to her and where she felt comfortable. But, before I continue, let’s take a pause here and discuss some important statistics around transition-of-care.
Did You Know?
· The transition from hospital to home (transition-of-care) is one of the most vulnerable periods in a patient’s care journey. Between 20-22% of patients discharged from the hospital are readmitted within 30 days, and many of these are considered preventable.
· The estimated annual costs of readmissions are over $50 billion, and are tied to communication breakdowns, misunderstanding discharge instructions, and confusion about medications.
· Research shows that 60% of medication errors occur during care transition periods, and 72% of post-discharge adverse events are medication-related.
· Integrating family caregivers into discharge planning can significantly reduce the risks of readmission – 25% at 90 days and similar reductions at 180 days.
These statistics underscore the importance of clear medication reconciliation, thorough discharge teaching, and active follow-up to reduce confusion, prevent errors, and keep patients safe at home. I always tell family caregivers that the day your family loved one is admitted to a hospital is the day you start planning their discharge. It takes that much planning. Without proper support and planning, the risk of complications, preventable hospital readmissions, and caregiver stress skyrockets. Add to the stress a caregiver’s other responsibilities, such as holding down a job, caring for other family members, and their own personal needs, and you can have a caregiver crisis.
Now, Back to Mom
Once I arrived at my mom’s hospital room, I did not leave her side except to go to the hotel and sleep for a few hours. I don’t recommend this. Try to have a team of family members or friends help out by taking turns. I was able to speak to early morning staff physicians, nurses, case managers, and physical therapists. I was able to connect with the case manager (a very important role, which a social worker on the hospital staff is assigned to a patient and their family to manage their overall care), and I started planning for mom’s transition of care back to her nursing facility.
Within two days, I was able to get her discharged and back to her nursing home. Before discharge, I made sure a solid transition plan I fully understood was in place, and I had it printed out (two copies), one for me and one for her nursing home staff, as well as emailed. She was discharged on a Sunday, so the staff that cares for her during the week was not there. I was diligent in following up with everyone on Monday so that the transition-of-care plan was in place and followed. I spoke with key staff members like the Director of Nursing, Unit Nurse, Dietitian, Occupational Therapy, etc.
Mom is doing okay, but noticeably weaker. I continue to advocate for her even though I’m doing so mostly from a distance. I have “eyes and ears” on site that will notify me of any changes to her condition, and I talk to her 1-2x a day. If you take nothing else away from my story, remember that a solid and understandable transition-of-care plan is a critical component of patient recovery. Of course, we don’t want hospitalizations to occur, but you will be in a better position to acknowledge the possibility and, more importantly, to be prepared, just in case. Remember, the day a family member is admitted to the hospital is the day you start planning to get them back home safely.
Advocate! Advocate! Advocate!
As we saw from the data, caregiver advocacy is a major determinant of success in transition-of-care. When a caregiver is informed, prepared, and empowered, outcomes measurably improve. Strong advocacy means asking the right questions, keeping track of appointments and medications, and ensuring the patient understands what to do next. It also means communicating with healthcare providers when something doesn’t feel right. For patients who are fatigued, cognitively impaired, or overwhelmed, having an advocate can be the difference between a smooth recovery and a setback.
A Note to Employers
Hospital-to-home transitions directly affect employers through healthcare costs, productivity, and workforce stability. Avoidable readmissions significantly contribute to employer-sponsored health plan spending. Employees caring for a loved one recovering from hospitalization often face delayed return-to-work, absenteeism, or reduced productivity when transitions are poorly managed.
Employers that prioritize transition-of-care benefit from improved employee retention, lower healthcare costs, and a more resilient workforce. Also, supporting caregivers through flexible policies and education strengthens both employee well-being and organizational performance.
Until the next blog! Thank you for being here, for reading, and for caring!
References
- Centers for Medicare & Medicaid Services (CMS). Hospital Readmissions Reduction Program