Helping Seniors Return Home After a Hospital Stay

Every year, over 13 million older adults in the United States make the difficult transition back home after a hospital stay.  The move requires coordinated support from both the hospital and the community.

“Without the right assistance, older adults are at risk for re-hospitalization and for poor health outcomes.” says Robyn Golden, director of older adult programs at Rush.

Concern about how seniors fare when they return home was the impetus for a remarkable program at Rush, called the enhanced discharge planning program.

Under this program, social workers follow up with at-risk older adults by telephone to conduct a post-discharge assessment and coordinate necessary short-term care. A study of the program found that issues requiring attention occurred in 83 percent of the cases. For 74 percent of these individuals, the problems did not emerge until after hospital discharge. The study also found that those who received services, versus those who did not, were significantly more likely to follow up with their doctors after discharge, which is a vital contributor to positive health outcomes.

The program at Rush has been so successful that it inspired creation of the very similar Bridge Program, which has been implemented statewide by members of the Illinois Transitional Care Consortium, including Aging Care Connections, the Shawnee Alliance for Seniors, Solutions for Care, the University of Illinois at Chicago School of Public Health, and the Health and Medicine Policy Group, as well as Rush.

And now, that Bridge Program, including Rush’s enhanced discharge planning program, has received a federal grant supporting its expansion to younger persons with disabilities.  .

“As health care costs continue to skyrocket, the Bridge Program will help provide the elderly and those with disabilities with the support necessary to live healthy in their own communities, and will highlight Illinois as a leader in innovative solutions to the complexities and challenges of providing high quality transitional care, while containing costs, Golden says.

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