This article was written by Dave Young, Ph.D, the Vice President of the Center for Clinical Excellence at Seniorlink, the parent company of Caregiver Homes.
Earlier this year, Harlan Krumholz, MD, a cardiologist at the Yale New-Haven Hospital Center for Outcomes Research and Evaluation, published a provocative article in the New England Journal of Medicine titled "Post-Hospital Syndrome: An Acquired, Transient Condition of Generalized Risk". In the article, Dr. Krumholz reminds us that recently hospitalized patients are not only recovering from the illness or condition that prompted the hospitalization but are also experiencing a period of generalized risk for a range of adverse health events. He calls this an acquired "syndrome" that involves a temporary period of extreme vulnerability for other health problems.
Naturally, the post-hospital syndrome will vary from patient to patient based on a host of factors. However, care providers – notably those providing Home and Community-Based Services – should be on the lookout for changes in behavior that could include: heightened stress, sleep disturbance, medication changes, cognitive changes and deconditioning that can alter the ability to perform daily living activities. These changes often occur regardless of the original cause for hospitalization; it is a syndrome that can apply to all recent discharges in consumers – both young and old.
Home and community-based service providers, especially those assisting elders, should be comprehensively evaluating patients returning from the hospital for changes that might exacerbate the primary problem (that led to the hospitalization) as well as the syndrome of potential changes described by Krumholz. Details about the hospitalization should be gathered along with a comprehensive re-assessment of medical, functional and emotional status of the patient.
Critical-thinking questions should be asked. Here are some examples.
- Is the caregiver and family able to provide the post-hospital care needed?
- What is the potential caregiver strain (burden)?
- Does the caregiver need education about care requirements?
- Do caretakers have knowledge of the "red-flags" to look for so that decline can be identified early?
Dr. Krumholz suggests that community care providers use "risk-mitigation" strategies that go beyond the cause of the initial hospitalization to look at the potential for infection, medication adverse events, falling and confusion, just to name a few. He suggests that strategies aimed at reducing disruptions in sleep and pain be addressed. Good hydration and nutrition should be emphasized along with judicious, careful physical reactivation and re-introduction of leisure outlets.
Great care transition work in the community starts with great communication between all providers. When a consumer, especially an elder who needs help with several activities of daily living, returns from the hospital, a coordinated care team approach is advised; one that engages in a comprehensive assessment of patient requirements as well as the strengths and needs of the caregiver and family. By identifying areas of risk and then creating care plans that specifically address them in a person-centered manner, the risk of rehospitalization will be greatly reduced.
This is a "win" for all: the consumer is healthier and happier, caregivers feel more capable of providing the supports needed, and avoidable costs are eliminated.