By Sindy Von Bank, Director of Strategic Partnerships, Healthcare Division of Connect America

The rate of hospital readmissions in the U.S. is staggering and has been a national priority for payers, providers and policymakers for years. Research suggests nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, totaling roughly 2.6 million seniors, and costing more than $26 billion annually. Equally concerning is that nearly half of these readmissions may be preventable.

A successful transition from hospital to home can help reduce the risk of medication errors, therapeutic errors, injuries, and infections that lead to unnecessary readmissions. Effective healthcare transitions require the successful transfer of information from clinicians to the patient and family to reduce the risk of adverse events and prevent potential readmissions. Engaging patients, families, and caregivers in this process is a key factor in making the transition safer.

The first 30 days after a discharge are typically the most critical for a patient’s recovery. Particularly for elderly adults who need attentive care and support to avoid complications that may lead to a readmission. Below are some best practices that caregivers and family members can take to help make the transition from hospital to home as safe as possible.


The first step to a safe care transition and preventing hospital readmissions is communication. This is why it is critical for family members and caregivers to speak in-depth with the patient’s doctor before discharge. Discuss how you can improve the transition from hospital to home and ask questions about how you can make it safer.

  • Understand medications, dosages and schedules. Request medication information and care instructions in printed form when possible.
  • Ask about any special procedures and special care that must take place.
  • Understand the risk factors for your loved one’s condition.
  • Learn the steps you can take to help mitigate these risk factors.
  • Understand what follow-up care is needed or if your loved one will require professional assistance.

Medication Management

A significant number of hospital readmissions are caused by medication-related adverse events. Research suggests nearly 20% of discharged patients experience an adverse event after discharge, of which roughly two-thirds are attributed to medications.

During hospitalization, many patients are prescribed new medications. Patients and family members should discuss these new medications in detail with the doctor. They should review how any new medications may interact with existing medications to avoid confusion. It is also important to discuss any side effects that should be expected.

  • Have a Detailed Medication Plan: Make sure to request a detailed list of exactly how to take all medications.
  • Utilize a Single Pharmacist: Working with a single pharmacy or pharmacist where all prescriptions are filled will significantly reduce the chance for medication errors.
  • Medication System: Develop an effective system to help organize medications and take them as prescribed.

Develop a Care Plan

After a hospital discharge, most patients will need help making arrangements for follow-up care, transportation, and coordinating appointments with their doctors for continuity of care. These follow-up visits are important for recovery and preventing readmission.

A care plan can help ensure these steps do not fall through the cracks.

  • Ensure that family members or care professionals are available to monitor and support the patient 24/7 for the first 30 days as needed and coordinate a care schedule.
  • Educate all family members and caregivers on medication dosages and schedules, care procedures and risks.
  • Determine what items or materials the patient or family member may need during this time and procure them.
  • Discuss maintaining a home exercise program with the nurse, physical therapist or caregiver.
  • Fill the refrigerator with healthy food items and consider scheduling Meals on Wheels, Uber Eats or other meal services during this time.
  • Conduct an in-home safety assessment to help reduce the risk of injury or falls.

Fall Prevention

Fall-related injuries are a leading cause of hospital readmissions, particularly for at-risk older adults transitioning from the hospital to home. Research has shown that between 29-45% of seniors fall during the period after discharge from a medical, surgical, or rehabilitation facility. Patients are especially vulnerable to falls after a hospital stay, which is why caregivers and family members must pay special attention to fall prevention measures. Below are a few steps that can be taken to help reduce fall risks and ensure the safety of your loved ones:

  • Make sure to remove all home hazards from high-traffic areas such as boxes, electrical cords, coffee tables, side tables and magazine stands.
  • Remove or secure all loose rugs in the home.
  • Use nonslip mats in the bathtub or shower.
  • Place night lights in the bedroom, bathroom and hallways.
  • Make sure the patient wears properly fitting, sturdy shoes with nonskid soles.
  • Secure handrails on both sides of the stairwell.
  • Install nonslip treads for bare-wood steps.
  • Install grab bars for the shower or tub.
  • Consider using a cane or walker for stability.
  • Consider utilizing safety-enhancing technology such as a Personal Emergency Response System (PERS).

Remote Patient Monitoring and Safety-Enhancing Technology

Caregivers and family members of patients who have recently been discharged from the hospital or have transitioned back into the home often utilize remote patient monitoring (RPM) and safety-enhancing technology such as personal emergency response systems (PERS). In fact, demand for these devices has skyrocketed over the past few years.

RPM and telehealth solutions allow seniors to receive continuous monitoring and care from the comfort of their homes or outside traditional clinical settings. The technology enables clinicians to monitor vital signs and health data to remotely manage their patients’ care enabling earlier interventions and ultimately better outcomes. RPM has been proven to help reduce hospital admissions by nearly 40% and readmissions by as much as 60%.

PERS, also known as, medical alert systems, are a proven, cost-effective solution that enables the monitoring of seniors from the comfort of their homes while providing 24/7 access to assistance and care. Whether returning home from the hospital or to be used on the go, PERS allows seniors to independently age in place while increasing safety and reducing risk. PERS has also been shown to reduce hospital admissions by up to 25%.¹

Remote patient monitoring solutions and personal emergency response systems help seniors successfully age in place through the management of care and safety to prevent readmissions and keep seniors healthy and independent. So, before a patient or loved one is discharged, consider taking these steps in your hospital-to-home care plan.


  1. Koch, J. Emergency response system assists in discharge planning. Dimensions in Health Service, 61, 30-31.