10 Innovative Ways Knute Nelson Helps Prevent Readmissions

Feb 14, 2020 by Maria Thompson

Your loved one is finally at home. The last place they want to go is back to the hospital.

High readmissions rates are a serious concern across the country. They also contribute to rising health care costs.

For your loved one, a trip back isn't just unwelcome. It's stressful, both physically and emotionally.

Prevention is the key to curbing readmissions. Here are ten ways we help prevent them for short-term rehab and home care patients.

Short-term rehab

1. Day one. Planning for a successful transition to home starts on day one. What are Mom or Dad's goals? Getting back walking with friends? Golfing? Living independently at home? We honor their goals whether they're realistic or not.

2. Home care after discharge. Home care provides a bridge to success at home. Before beginning care plans, staff identify anything that could send Mom back to the hospital – from throw rugs and uneven steps to managing medications.

3. Follow-up appointments. There's a flurry of activity around discharge. It could be easy to forget to make a follow-up appointment with Mom or Dad's doctor. We take care of that for them. We also make sure they have a way to get there and back.

4. Communication with clinics. Medications often change during short-term rehab. Before discharge, we send Mom or Dad's new medication list to their doctor's office. They won't need to remember to take an updated list to their follow-up appointment.

5. Pharmacy access. Once Mom leaves short-term rehab, she'll need to refill and pick up her own medications. Before she goes, we make sure she's able to do this. Or, find a pharmacy that delivers.

6. Medication management. Taking too much, too little or the wrong medication is a significant contributor to readmissions. Before your Mom or Dad leave, we assess whether they understand how to, and will take, them as directed. If they need help, home health care can set this up for them.

Home Care

7. Assessment and care plan. When Mom begins home care, we look at everything that could send her back to the hospital. We assess from head to toe and all around her living environment. All of this is included in her personalized care plan.

8. Telehealth. Patients use a tablet to connect health monitoring devices – scales, blood pressure cuffs, pulse oximeters – to a telehealth nurse who reviews the information (and will intervene if anything is amiss).

Tablets also have educational videos that will help patients learn more about managing their disease.

9. Personal emergency response pendant. We'll work with you and your loved one to figure out what will work best in your situation. We can also install it in your loved one's home and troubleshoot as necessary.

10. MedSmart. If Mom or Dad take multiple medications at different times of the day or week, MedSmart can help them do so safely. A nurse or a family member fill the medication box and sets the timers. The box then dispenses the right dose at the right time. Because it's locked, Mom can't accidentally take multiple doses or move medications to another time or day. MedSmart also notifies the telehealth nurse if Mom misses a dose.

While some readmissions are preventable, some aren't. We keep our eyes on prevention so your loved one can transition to home, and stay there. Because if given a choice, we'd all prefer to live at home.