When a parent keeps ending up back in the hospital

Why this comes up

Your mother came home from the hospital in August, was back inside three weeks, and came home again. Now something is off again, and you are sitting in a parking lot at nine at night working out whether to take her to the emergency room or wait until morning.

If you have been wondering what you missed, the answer is probably nothing. A hospital sends a person home with a folder of instructions that assumes somebody at the house has the time, the vocabulary, and the standing to carry them out, which in most families nobody does. The gap is built into how discharge works, and nobody tells families that closing it has become their job.

You do not have to settle any of this tonight.

How often families go through this

The federal Agency for Healthcare Research and Quality counts how often patients land back in a hospital within 30 days of leaving one. In its analysis of 30-day all-cause readmissions from 2016 through 2020, Medicare patients aged 65 and older were readmitted 16.0 times per 100 index hospital stays in 2020, almost the same as the average across the four years before it.

That report does not sort those returns into avoidable and unavoidable. So the number tells you that roughly one Medicare patient in six over 65 is back inside a month, and that your family is in very ordinary company. It cannot tell you which of your mother's trips could have gone another way. Her clinic can go through her own record with you to answer that.

What tends to send a parent back

The question most families ask first is why this keeps happening to their own parent. National data cannot answer that about one household. Discharge conversations usually turn up the same handful of causes, and some of these will match her situation.

• Medications taken twice, taken at the wrong hour, or not taken at all.
• A change nobody catches between appointments: weight climbing in heart failure, new confusion that turns out to be a urinary infection, a wound that is not closing.
• A fall, often in the bathroom or on the way to it at night.
• Too little food and water, which can start with a parent who cannot stand at the counter long enough to cook.
• A follow-up appointment missed because nobody was free to drive her to it.

All of these happen during the hours when no professional is in the house. Most families start with whichever one frightened them most recently.

What Medicare pays for once she is home

Families often expect the hospital to arrange ongoing help at home. What the hospital arranges is usually a set of skilled visits. Hospitals rarely put these rules in the discharge folder, so many families hear them for the first time after they get home. Medicare's page on home health services sets three conditions. A doctor or other qualified provider has to see her in person, certify that she needs the care, and order it. She has to need part-time or intermittent skilled care such as nursing or therapy. And she has to be homebound, which means leaving home is not recommended for her condition or takes a device, another person, or considerable effort. The agency providing the care has to be Medicare certified.

When all of that holds, Medicare pays for visits. The same page puts skilled nursing and home health aide time at up to 8 hours a day and 28 hours a week combined in most cases, and up to 35 hours a week for a short stretch if the provider decides it is necessary. It also lists what the benefit leaves out, including "24-hour-a-day care at your home," "home meal delivery," "homemaker services (like shopping and cleaning) unrelated to your care plan," and personal help with bathing, dressing, and toileting when that is the only care she needs. Many families expect the bathing and dressing to be covered, and paying for that help out of pocket is expensive.

So Medicare pays for the nurse who stops by twice a week to check a wound. It does not pay for somebody to be there at seven in the morning to get her safely out of bed. Home care or home health explains the difference between the two in more detail. Plenty of families only learn it after the first bill, which is a rotten way to find out.

What paid hours at home can change

Ongoing hours at home are generally paid privately or through a long-term care insurance policy. Abloom Senior Living provides in-home care across the East Metro under a comprehensive home care license from the Minnesota Department of Health, and families pay privately or through their long-term care policy. If what you need is waiver-funded care at home, you will be told that plainly and given the name of someone who can help with it.

Hours usually get built around the parts of the day that go wrong: the morning routine, the evening, the stretch of afternoon when a working daughter cannot be there. For a parent who has been in and out of the hospital, the most useful tasks tend to be the routine ones. Someone watches the pill box and reports what is not getting taken; the question of which medication tasks an aide may handle and which ones a nurse has to delegate is covered in who can give medications at home. Someone notices on Tuesday that her ankles are larger than they were on Friday and calls the clinic before the weekend, and someone makes sure she is eating.

What an agency is licensed and staffed to handle matters too. If she comes home with a feeding tube, a BiPAP machine, or needing two people to move her safely, ask any agency you talk to what its license and its staff allow. In-home care under a comprehensive license can include nursing visits, tracheostomy care without a ventilator, feeding through a G, J, or GJ tube, BiPAP, CPAP, and oxygen, two-person transfers, and dementia care at home. The page on post-hospital care describes how the weeks right after a discharge usually get staffed. Overnight hours are staffed as awake shifts, and no caregiver sleeps at the house; the page on overnight and around-the-clock care explains how those shifts work.

Nobody can promise you that hours at home will keep your mother out of the hospital, because some return trips are caused by the illness itself. Paid hours put someone in the house who can see a change early and call the clinic about it.

What a Minnesota agency owes you in the first two weeks

Under Minn. Stat. 144A.4791, a comprehensive home care provider has to have a registered nurse complete an in-person assessment within five days after services first begin, and has to finalize a written service plan no later than 14 days after that start date. The plan has to be signed by the agency and by your mother, or by whoever speaks for her, and looked at again at least every 90 days. Before services begin, the provider also has to give you a written notice of the home care bill of rights and a written statement saying whether its license is basic or comprehensive, along with what it can and cannot provide.

Put those dates on the calendar. If no nurse has been to the house by day five, or there is no signed service plan in week two, you have a specific thing to ask the agency about. The agency already works to these dates, so asking about them is a routine question.

Free help before you spend anything

Minnesota Aging Pathways, formerly the Senior LinkAge Line, is a free statewide service of the Minnesota Board on Aging. Its counselors will work through Medicare coverage, long-term care planning, prescription costs, and what exists locally, at no charge, and they have nothing to sell you. The number is 800-333-2433, and there is more about what they handle in free help for East Metro families arranging care.

Washington County and the Metropolitan Area Agency on Aging are the other two places to call in the East Metro. If you have time for only one call this week, start with Minnesota Aging Pathways and ask which of the other two to call next.

When home no longer works

Sometimes the third trip is the one that shows she cannot stay safely at home, even with paid hours. Families often keep adding hours well past that point, usually because a move feels like a decision that cannot be taken back. When to consider a move goes through the signs. It is a fair question to keep open for a while; you can also add hours now and look at a move in the spring.

Abloom Senior Living also operates a five-resident customized living home in Woodbury. It is the same company, so a family already arranging care at home through it would not be starting a search from nothing if home stops working.

Where to start

If you want to talk through what the next few weeks at home would actually need, you can request in-home care and describe the situation in your own words. Someone will come out and look at the house with you, or you are welcome to come see the Woodbury home first. Abloom Senior Living may not be the right fit for your family. If that turns out to be the case, you will be told so and pointed toward someone who is a better match.

This article is general information from a care provider in Woodbury, Minnesota. It is not legal, financial, or medical advice. Coverage rules, program figures, and your parent's clinical situation all turn on specifics, so check anything here against your parent's own plan, her clinic, and the agency you are considering.

Frequently asked questions

Does Medicare pay for someone to stay with my mother after a hospital stay?

No. Medicare's home health page lists "24-hour-a-day care at your home" among the things the benefit does not cover, and personal help with bathing, dressing, and toileting is excluded when that is the only care she needs. Medicare pays for part-time or intermittent skilled visits when she is homebound and a provider has certified the need. Ongoing hours are generally private pay or long-term care insurance.

How soon after a discharge should care at home start?

Most families aim for the first day home, because the first week is when the medication list, the follow-up appointments, and the new equipment all get sorted out at once. If the discharge has already happened, you can still arrange it; agencies take calls the day of a discharge.

Can a home care aide give my mother her medications in Minnesota?

It depends on the task and the license. Minnesota draws a line between assisting with medications and administering them, and some tasks have to be delegated by a registered nurse. The journal post on who can give medications at home, linked above, covers how that line gets drawn.

Will having care at home keep her out of the hospital?

Nobody can promise that, and any agency that does is overselling. What hours at home add is somebody present who sees a change early, keeps the medication routine on track, and calls the clinic before a problem becomes a weekend emergency.

What if we cannot keep paying for ongoing hours?

Call Minnesota Aging Pathways at 800-333-2433 before her savings are gone. More programs are open to her while she still has savings than after they are spent. Counseling on long-term care planning and public programs is free, and the counselors know which Washington County and state programs exist. Abloom Senior Living does not accept Minnesota waivers or Medical Assistance for in-home services, so a family who needs waiver-funded care at home will be referred elsewhere.

Related reading

• Coming home after a transitional care unit stay
• What to ask at a hospital discharge meeting
• Does Medicare cover in-home care?

Sources

• Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Characteristics of 30-Day All-Cause Hospital Readmissions, 2016-2020 (Statistical Brief #304)
• Medicare.gov, Home health services coverage
• Minnesota Office of the Revisor of Statutes, Minn. Stat. 144A.4791
• Minnesota Board on Aging, Minnesota Aging Pathways