Readmission Rates for Medicare Patients Are Staggering

readmission rates for medicare patients are staggering... create a discharge plan | Care for You

Fragmented Healthcare System or Not, as Healthcare Professionals It’s Up to Us to Do Better

Ask just about any healthcare professional—medical or nonmedical—and they’ll tell you that hospital readmission rates for Medicare patients are staggering.

According to the Dartmouth Atlas Report, “Medicare patients over age 65 are admitted to the hospital over nine million times annually. Almost one in five of these patients are readmitted within a month of discharge…”

And if they’re worth their salt, they’ll also tell you that we need to do better than that for our aging clients—that in fact, as caregivers, doing better is our responsibility.

The need for hospitalization and acute care following any number of episodes such as stroke, heart attack, or a broken hip are unavoidable…

And transfer of a patient to a rehabilitation facility once they have been stabilized, but still aren’t back to full capacity, only makes good sense—physical independence in the home is impossible at this stage, anyway…

But when patients do leave a hospital or rehab facility, it is usually without a discharge plan, and even the ones who have a plan rarely have the ability or support to achieve its objectives.

That part doesn’t make sense, and it’s absolutely avoidable.

Creating a Discharge Plan

From the Dartmouth Atlas Report:

“Care coordination needs to be a continuous process that begins before illness warrants hospitalization, continues when hospitalization is necessary, and seamlessly moves back into the community.”

A strategy to accomplish this seamless move back into the community and home might include asking two simple questions:

“Is home a safe discharge?”

“Is home care needed?”

Answering these questions as early on as possible—preferably at the time of admission rather than at discharge—allows for preparations to be made and can dramatically impact the client’s chances of success.

With a discharge plan in place we are able to:

• Prepare a person’s home to support them in their current state; e.g., if there is no bathroom on the first floor, a stair lift can be installed so the person may continue living there.
• Attend to clutter, unsanitary conditions and potentially dangerous objects (throw rugs, extension cords, etc.).
• Supply the home with food and other needed commodities.
• Fill prescriptions.
• Ensure proper nutrition and hydration by scheduling professional personnel to assist the patient, especially in the first several days after discharge.

By looking ahead, creating and implementing a plan to support our loved ones, the chances of readmission can be significantly lowered.

We believe this should be standard procedure—what should be done—because doing it equals better.



Continue this conversation by calling us at 301-650-4169 or email

We look forward to working with you.



Free Download: After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries