A hospital readmission is costly and stressful for the patient, family, and clinician.

One goal in home health care has been to reduce the number of patients who need to be readmitted to the hospital soon after an illness. In order to improve quality and limit cost, Medicare can even fine an agency with high readmission rates.  It has become customary for home health agencies as well as hospitals, to review readmission rates on a regular basis, in order to keep that percentage low, and serve their patients well.

A Social Work Assessment may help a patient avoid returning to the hospital.

Most seniors receiving home care have a great recovery.  Occasionally the situation is obviously difficult, and we call right away for a social worker to assist.  Many times however, we find ourselves right on the line and unsure whether or not a patient truly needs the assistance of a social worker.  There are many reports regarding patients who are at risk, that we can use to guide our decision.

Click here to access a FREEBIE/Social Work Checklist to help decide if a patient would benefit from an assessment.

Understanding readmission data may help you decide if a patient would benefit from a Social Work Assessment.

A study from 2001, looked at hospital readmission for seniors, and found 30 percent were due to medication issues, and 50 percent of those were considered preventable. (M Chan, 2001)

Medication questions to consider: do they take multiple medications, has there been a significant change in their medication, do they have physical or financial issues limiting access to medication, are they organized with their medication? A social worker may be able to provide assistance with certain medication issues.

Stay organized by using a medication organizer to help improve consistency with your medications (affiliate link). Print out the freebie medication list at the end of this post!!

Along with medication issues, consider language or learning ability possibly limiting comprehension of instructions. Home safety/home environment (see my post on patient safety and home safety equipment) can also play a factor in the healing process. A social worker may be able to assist a clinical team in those areas as well. (Cipherhealth 2020)

Be familiar with diagnosis groups at greatest risk of readmission.

Knowing which diagnosis groups are most at risk for readmission may assist with a borderline decision. A study of medicare/medicaid unplanned readmissions looked at 7, 15, and 30 day readmission percentages. Here are the diagnosis groups that had the greatest frequency of readmission: (Medinsight, 2019)

HEART FAILURE was in the top 3 diagnosis families for 7, 15 , and 30 day readmissions.

GASTROINTESTINAL was in the top 3 for all time points. 

CARDIAC ARRHYTHMIAS with in the top 3 for the 7 and 15 day readmissions.

MENTAL HEALTH DISORDERS was in the top 3 for all time points. 

SEPSIS was in the top 4 readmission’s rate at 30 day, and is a more frequent admission in general.  

It may be helpful to keep these diagnosis time points in mind, when you are working with a patient who might need some extra help. How you plan your visits, or getting assistance via social services for those at greater risk, may be enough to keep them safe at home!

Seniors and caregivers, check this link to look up your local hospital readmission rates.(KHN, 2021)

Fall risk is another area important to consider after being hospitalized. Make sure to set your clients/ loved one up for success by arming them with education and home resources that will help prevent a fall. Here is a link to a packet full of evidence based info, and of peer reviewed senior focused health handouts for documenting clear safety education and activity at Etsy.com.

Here is a freebie printable med list to help you stay organized!

You may also like: hospital discharge organization tips and 10 Tips to be an Organized Caregiver.

What other information do you consider for readmission risk and need for social work assessment? I would love to hear from you! Begin your Organized Healthcare Journey by subscribing to the blog for weekly senior care tips and a few printable FREEBIES!

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