Preventing Hospital Readmissions: How Home Care Can Make a Difference

Returning home after a hospital stay should be a time of recovery, yet many older adults find themselves readmitted due to preventable issues. Some of the most common reasons include:

• Managing Chronic Conditions – Long-term conditions such as diabetes, heart disease, and respiratory illnesses require ongoing care. Without proper monitoring and early intervention, complications can escalate quickly.
• Medication Mismanagement – Forgetting to take medication, taking incorrect doses, or experiencing side effects can lead to serious health risks.
• Falls and Accidents – Falls at home are common and can sometimes lead to injuries requiring medical attention.
• Nutrition and hydration – Maintaining a healthy diet and staying hydrated is essential for recovery and overall well-being
• Personal Care – Personal care support helps maintain hygiene and comfort, reducing the risk of health concerns.
• Social Isolation and Mental Health Concerns – Staying socially connected is important for both emotional and physical wellbeing.

Understanding these risks allows for preventative action—something that personalised home care is designed to provide.

Monitoring Health Conditions

We use a number of early indicators to alert us to changes in our clients wellbeing such as Visual Health Check and Clinical Frailty score, both of which allow us to pick up on clients vulnerability early to enable treatment at home, and further assessment and to avoid the need for hospitals wherever possible. Care in hospitals is recognised to lead to deconditioning in the elderly. The frailty index is an NHS recognised tool we use at Home Instead to monitor current health and to signpost any healthcare response that may be required. This has been proven to improve outcomes significantly. 

You can find more about how we use Clinical Frailty Score to avoid hospital admission at: Preventing Hospitalisation: Introducing the Clinical Frailty Score at Taunton Home Instead | Home Instead

Our Care Professionals are trained to recognise early warning signs that may indicate declining health. Using an ‘Early Warning Signs’ tool, we monitor:

• Changes in mobility or movement.
• Loss of appetite or difficulty eating.
• Increased confusion or agitation.

By identifying these signs early, we can ensure timely intervention before a hospital visit becomes necessary.

Nutrition and Hydration Support

Good nutrition plays a key role in recovery and long-term health. Our team ensures clients receive well-balanced meals and stay hydrated by:

• Preparing nutritious meals tailored to individual dietary needs.
• Encouraging regular fluid intake to prevent dehydration.
• Monitoring eating habits and reporting concerns to family members or healthcare providers.

Companionship and Emotional Well-Being

Social isolation has a direct impact on physical and mental health. Our companionship services help prevent loneliness and provide:

• Meaningful conversations and engagement in activities.
• Regular mental well-being checks to identify signs of depression or anxiety.
• Emotional support that promotes confidence and independence.

Co-ordinating Care with Healthcare Professionals

We work closely with local GPs, district nurses, and hospitals to ensure our clients receive seamless care. Our role includes:

• Helping to arrange and attend medical appointments.
• Liaising with healthcare providers to address medical concerns.
• Supporting clients with wound care, rehabilitation exercises, and post-hospital recovery plans.

Reducing hospital readmissions is not just about immediate post-discharge care; it requires a long-term strategy. Here’s how home care can be part of a sustainable solution:

Better Discharge Planning

Hospitals that implement structured discharge planning reduce readmission rates by ensuring patients leave with:

• A clear care plan, including medication schedules and lifestyle adjustments.
• Follow-up appointments arranged before discharge.
• A support system in place to manage daily tasks at home.

Post-Discharge Support and Home Visits

Regular home visits from Care Professionals help address any health concerns early, supporting continued recovery. Additional support such as telemonitoring and check-in calls can also help maintain stability at home.

Family Involvement and Education

Families play a key role in preventing readmissions. We provide guidance on:

• Recognising signs that medical attention may be needed.
• Understanding medication schedules and dietary needs.
• Creating a safe and supportive home environment.

Technology and Remote Healthcare

Innovations in healthcare technology are helping to bridge gaps in care. Digital health apps, remote monitoring tools, and virtual consultations allow older adults to receive medical advice without needing to visit a hospital.