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Reducing Hospital Readmission

Hospital readmission is an all-too-common occurrence for many older adults shortly after discharge.

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Strategic Partnership: Reducing Hospital Readmissions with Specialized Post-Discharge Care

Hospital readmission is a significant and costly challenge, often stemming from inadequate transition planning and a lack of continuous support in the post-acute setting. For older adults, the vulnerability following discharge is compounded by factors like post-hospitalization syndrome and difficulties adhering to complex care regimens.

We are seeking to partner with healthcare professionals and systems committed to improving patient outcomes, reducing unnecessary utilization, and minimizing readmission rates.

ComForCare: Your Partner in Transitional Care Excellence

ComForCare offers a specialized, non-medical in-home transitional care program designed to bridge the gap between hospital discharge and full recovery. We extend the continuum of care into the patient's home, serving as an integral, non-clinical layer of support to mitigate readmission risk caused by preventable incidents.

Our program is specifically designed to support patients recovering after hospitalization or a stay in a skilled nursing or rehabilitation facility.

How Our Caregivers Lower Readmission Rates

Our professional caregivers are trained to provide essential, non-medical support that directly impacts recovery compliance and safety in the crucial post-discharge window.

Medication Adherence Support

We provide medication reminders and oversight to ensure the patient adheres to prescribed schedules, addressing a common cause of post-discharge deterioration. We can also coordinate pill box set up as needed.

Personal Care Compliance

We assist with critical daily activities (e.g., bathing, dressing, toileting, personal grooming). Ensuring these needs are met prevents the patient from overexerting themselves, allowing for proper rest and recovery.

Safety and Fall Prevention

By providing support with mobility, transfers, and light housekeeping, we minimize the risk of falls, a leading cause of readmission for seniors.

Nutrition and Wellness

Caregivers assist with meal preparation and ensure the patient has necessary groceries (errands), supporting nutritional stability essential for healing.

Early Detection and Proactive Reporting

Our caregivers maintain a meticulous watch, particularly in the critical first 2 to 7 days post-discharge. They are trained to identify subtle changes indicative of complications, such as:

Worsening symptoms or signs of infection.
Confusion, increased disorientation, or signs of post-hospitalization syndrome (e.g., changes in bowel/bladder function, heightened anxiety, or fatigue).
Signs of medication side effects. This early intervention allows the patient's primary care provider or discharge team to take prompt, proactive clinical action—reducing the likelihood of an unnecessary ED visit or readmission.

Addressing the Root Causes of Readmission

There are seven critical touch points that get missed, which lead to poor outcomes. ComForCare has developed a program that covers all seven touch points systematically from medication reconciliation to care coordination for the first 30-days of care.

What do we do:

Reduce readmission risk
Ensure adherence to medication protocols
Implement evidence-based fall risk reduction
Deliver condition-specific care & outcomes
Prepare families for the transition home
Coordinate compliance packaging for medication management

7 touch points in the first 30 days of home care

Day 1 - 3: Assessment, client and caregiver specific disease training, review discharge paperwork, caregiver/client introductions, medication reconciliation and review. Complimentary compound pharmacy coordination provided for medication set up. Proactive outreach of calls

Day 7: PCP follow-up, proactive outreach calls

Day 14: Family education, proactive outreach calls

Day 21: Agency owner/operator in person visit, review additional needs requiring resource coordination, proactive outreach calls

Day 30: Outcome assessment, proactive outreach calls, unannounced wellness visit.

Post-hospitalization often leaves seniors fatigued, functionally declined, and overwhelmed by self-care. They struggle with maintaining routines and following complex discharge instructions. Our comprehensive support program is tailored to stabilize the patient during this vulnerable period, ensuring they can focus solely on recovery without the burden of household management or personal care deficits.

Let us become an extension of your care team, providing the non-clinical support necessary to achieve optimal patient outcomes and measurable reductions in hospital readmissions.

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