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Listen Up, What Doctors Aren’t Communicating Effectively to Seniors Christy Rakoczy

May 23rd, 2013

DrCommunicationIn a time when hospital readmissions rates are being closely analyzed and hospitals are attempting reforms to improve those rates, it is crucial to take a look at patient populations most frequently readmitted to hospitals and the reasons for readmission. Among those populations of people most frequently readmitted to hospitals, seniors are in great number. Poor discharge policies can be to blame.

When questioned about reasons for high readmission rates for seniors, many doctors cited the high motivation of elderly patients to leave the hospital as a cause for their lack of adequate care. Additionally, it was conjectured that older patients say they understand instructions for care when they do not, or are dishonest about the presence of a caretaker, all with the motivation of being released from the hospital. As a result, these patients do not recover as planned and must be readmitted to the hospital. Additionally, it was stated that many of these patients may choose to go to the emergency room over seeking care from a primary care physician.

However, other factors may be to blame. Various groups of the population require specialized understanding of potential social or personal issues that may prevent them from being able to follow through on care plans after hospitalization. In this situation, it is the responsibility of the healthcare practitioners to assess patients’ circumstances and needs and create plans accordingly for these patients. By changing the approach to these patients so as to focus on understanding their needs from a social and personal perspective, the overall care of senior patients can be greatly improved.

One issue that was cited by seniors as a reason for not following through on care plans provided to them is the inability to understand instructions from doctors. Rather than using layperson language, instructions are often written in doctor’s jargon and patients are unable to determine what they are supposed to be doing to follow up after hospitalization. By more clearly explaining, both orally and in written form, what the patient should do upon release from the hospital, doctors could greatly reduce the chance of readmission. Using the Teach-Back method is one highly effective way of achieving this goal.

Another issue that is cause for later readmission is the lack of support that many elderly patients have at home. Without a caretaker, many patients feel lost once home from the hospital. Educating these patients prior to discharge on the resources available in the community that may be able to help them would effectively reduce this problem. Additionally, providing a follow up coach that assists seniors in setting up appointments, ensures medication is understood and being taken properly, and who can also help with locating necessary community resources has been proven to improve overall patient care as well as decrease patient readmission.

For many seniors, the pure shock of their diagnosis can prevent them from being able to completely absorb the information given to them during their hospitalization. Again, giving extra care to ensure a patient understands instructions and providing follow up can dramatically improve patients’ understanding of how to care for themselves and seek follow up treatment.

Giving more attention to senior patients and to understanding the obstacles they may face in self-care and seeking post-hospitalization treatment has the capacity to greatly reduce the incidences of later readmission.


  1. Dedee, RN May 24, 2013

    This is yet another reason physicians and hospitals need to recognize and utilize home health agencies. It is a partnership with investing in.

  2. Karen May 24, 2013

    It’s a combination of the interdisciplinary team and working in conjunction with home health for continuity of care. Good discharge planning requires taking your time with patients. My issue is the high caseload. Like any agency when caseloads become too high, the client/patients are the ones who suffer.

  3. Charlene Jebens RN May 24, 2013

    What I see here is a description of what nurses are trained to do: Looking outside the single reason why a person is hospitalized and looking at all factors that impact the health of individuals. We need to support the extra time that a nurse has with her patients. We also need to refer to home care agencies to do follow up work. What is preventing hospital discharge planners from doing this simple task? I tell all my clients that when hospitalized they need to ask for home care. They should not be asking. I hear from them that the home bound status scares them. Tell me how many of those seniors who are going home soon after hospitalization will be out and about doing the things they use to do. Not many. Home care nurses are there to make sure that the discharge plan is understood and followed and if not followed works to get a plan that will be followed.

  4. Kathy RN/CM May 28, 2013

    The times that I have had concerns regarding a patient that is to be discharged, I will request a social worker consult along with home health. The social workers are also our eyes and ears. They are able to go into the house and see what is actually happening. Many times seeing the same picture as the nurse but from a different perspective. These two professions working together inside the home provide us with a very good picture of the patient’s needs that many times cannot be determined in the hospital.

  5. Alisa Hughley May 30, 2013

    Ideally nurses and social workers would work together to ensure a smooth discharge and home health agencies can help bridge the gap for any social determinants of health that present a challenge for seniors in following the plan. This post continues to underscore the need for excellence in health literacy practices. As another commenter observed, increased case loads make it challenging for social workers and nurses to work with and for patients in an optimum manner. It is my hope that redesign in reimbursement will alleviate these challenges. While senior patients most acutely demonstrate the challenges in adherence to discharge plans, these are challenges that can be faced by any patient. Effective communication and the time to make effective communication happen are key to improving the system.


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