Two thirds of hospital or SNF readmissions are from relative overall frailty that places patients at risk for all-cause illness. Two thirds of readmissions are NOT from the original reason for the index hospitalization. This major period of increased frailty to readmissions has been call “post-hospital syndrome”.
Modifiable risk for post-hospital syndrome includes preexisting chronic disease, lifestyle and the stressful hospital experience itself. To prevent readmissions, patients require a preventive self-management plan in order to know what they themselves can do to reverse post hospital syndrome at home. This readmission prevention care plan for home is currently not rendered.
This care plan needs to include specific and personalized instructions on how to self-manage:
During hospital and SNF downtimes in between care delivery, patients and families need to telehealth support from a prevention team of physiatrists and pharmacists. This telehealth support is facilitated by an onsite prevention navigator.
In addition to a rehabilitation medicine consult that addresses any barriers effecting functional recovery like pain, patients receive a self-management care plan and support for:
Patients also receive specialized telehealth tablets for home that enable physiatry-pharmacy teams to deliver readmission prevention utilizing best practices from proven models that include cardiac rehabilitation, pulmonary rehabilitation and the Lancet commission for dementia prevention.
