Making the Transition from Post-Acute Care to Home Care

Following a severe illness, injury or hospitalization, many older adults find themselves in a post-acute care setting, whether it’s a hospital or nursing facility. These special facilities and the services they offer help individuals gain control over long-term health issues not readily addressed at a regular hospital. These individuals need help with chronic conditions, medication management, rehabilitation services, skilled nursing care and many other expensive and time-intensive medical therapies. Medicare spending on post-acute care runs in the tens of billions of dollars annually, and in 2008 post-acute care accounted for a full 12 percent of Medicare spending, according to the American Hospital Association. Although older individuals often stay in the post-acute care setting for 25 days or more, many are not quite ready to go it alone when discharged. So where should these individuals go next? With some help in the transition, these patients can move back home.

Making the Move

Home care, care coordination and community-based health services, such as Program of All-inclusive Care for Elderly (PACE), can enable these individuals to get back to the safety, comfort and familiarity of their homes. These services have been found to be cost-effective compared to other care options. A report from The Hilltop Institute found Medicaid spends $2,055 more per member, per month for services in a long-term nursing facility compared to home care and community-based services. The transition from post-acute care to the home environment should be as smooth as possible. Home care services, care coordination and PACE work are three options to facilitate the shift.

Going Home (Care)

At-home care is a great option for caregivers and their loved ones following post-acute medical issues. For the patient recently discharged after an illness or one who is coming home following rehabilitation services, home care can create the safety net needed during the recovery time. Family members can also rest easy knowing their loved one is taken care of by a highly skilled healthcare professional. Home care providers receive extensive training, including learning about dementia and chronic conditions. Home care providers can also let families know about additional community services that may be available. Both skilled and nonskilled home care help with healing and recovery following a hospital or rehabilitation stay. Nonskilled home care can assist with errands or with housekeeping, while skilled home care can monitor prescribed medications.

Taking Care

Care coordination is especially helpful when family members live far away and may not have the opportunity to visit the loved one frequently. There are private-pay care coordination services overseen by a registered nurse, which include a number of important services to ensure the health and wellness of the individual. Phone calls are made to health care providers, appropriate resources are identified and needs are assessed via telephone or in the home. Care coordination is a long-term solution to assist individuals with ongoing health concerns. Listed below are some services an individual may receive through care coordination.

• Personalized health care recommendations
• Personal care and in-home support
• Health care provider appointment scheduling
• Person-centered dementia care and support
• Respite care for family caregivers

Stepping Out and Staying at Home

PACE programs are available around the country in many communities for those who qualify for Medicare and Medicaid. These adult day programs offer medical and dental care, socialization opportunities, rehabilitation services, meals, transportation and much more. Participants live in their own homes and typically take PACE-provided transportation to the centers, which are generally open Monday through Friday. An interdisciplinary care team assesses the individual’s needs and customizes a comprehensive care plan. The plan is implemented right in the PACE center through the in-house medical clinic, staffed by physicians and nurses. Regular re-evaluation ensures the individual always gets the care he or she needs. At the end of the day, the individual goes back home. Our responsibility as providers of health care services to older adults is to ensure they receive the best care in the most appropriate setting for their situations. And many times, thankfully, that “best care” allows them to be right where they should be: at home.