“When the hospital discharged me, I was told I had to take one medication every two hours and a different medication every three hours. The doctor said I was never to take the two together. I was sobbing in the middle of the night with a pen and paper in my hand trying to figure out this logic puzzle of when I could take my medication. Unsurprisingly, I was back in the hospital within weeks.”

– Evelyn, patient

“I got the call late on a Friday – always a bad sign. The hospital said, ‘This patient needs to be discharged today, and he needs home care.’ I went and sorted through the information at the hospital. His form said they were transferring all of his information to his family doctor. Right underneath, his chart clearly stated that he had no family doctor. So his health information was being transferred … nowhere. I found him a family doctor who would accept him as a patient and had the records transferred to her office. I catch little details like this all the time during hospital-to-home consultations.”

– Renée, president, ComForCare Home Care Toronto-Central

In Canada, one in 12 patients is readmitted to the hospital within 30 days of discharge. Dr. Irfan Dhalla, M.D., of St. Michael’s Hospital in Toronto notes that, “Returning to the emergency department shortly after discharge, or being unexpectedly readmitted, can be very stressful for patients and families.”

The Canadian Institute for Health and Information estimates unplanned readmissions cost the health system $1.8 billion a year.

One of the easiest ways to reduce the chance of readmission is communication. Clear, organized communication can decrease the incidence of hospital readmissions. Often, preventing readmission can be as simple as having someone present during the transfer of care who can receive all of the information from the hospital, read and understand it, and convey that information to the rest of the family and care team.

However, hospital discharges sometimes happen quickly, and family members cannot help with the transfer of care. Some family may live too far away to be present at the time of transfer.

To assist in these situations, ComForCare Home Care provides Hospital-to-Home services that include an assessment of needs with a personalized plan of care based on the assessment, as well as fall prevention suggestions and home safety checks. The ComForCare Hospital-to-Home package also includes:

• An experienced, reliable caregiver who meets your loved one in the hospital room or discharge area
• Transportation home with stops for picking up prescriptions or groceries
• Meal preparation
• Light housekeeping and laundry
• Receiving and disseminating discharge plans
• Bed tuck service
• A debriefing phone call to the family

ComForCare can help handle the big changes and small details that come with a discharge from the hospital and help prevent readmissions. Call 800-886-4044 for more information about Hospital-to-Home care.

Editor’s note: This article was originally published October 18, 2017. It has been revamped and updated for accuracy and comprehensiveness.