The “Hospital to Home” Journey: How We Reduce Readmissions

Stopping the Revolving Door: How Nurse-Led Care Prevents Hospital Readmissions

We get it. That specific feeling of relief that comes when a doctor says, “You’re fit for discharge.” And whether it’s you or an elderly parent, getting out of the hospital and back to your own bed is the ultimate goal. However, for many families, that relief is short-lived. Within weeks, or even days sometimes, complications can arise, infections take hold, or medications get mixed up. Thus, the ambulance is called again and readmission is inevitable.

This is known as the “revolving door” of hospital readmissions. And we know how exhausting it can be for the patient and how stressful it is for the family. But the good news?

It is often avoidable.

🏥 But First, Why Do Readmissions Happen?

You may have heard how the transition from a hospital ward to a home environment is a critical “danger zone.”

This is because in the hospital, a patient is monitored 24/7. Medication is dispensed by professionals, and fluids are measured. However, when they get home, that support structure vanishes.

Hence, the most common reasons for readmission include:

Medication Errors: Confusion over new prescriptions vs old ones.
Infection: Surgical wounds not being dressed correctly, or UTIs developing unnoticed.
Dehydration and Nutrition: Forgetting to drink or eat enough to aid recovery.
Delirium: Post-hospital confusion that leads to falls.

🤝 Bridging the Gap with Clinical Oversight

Now that you have a better understanding of why readmissions happen, this is where a nurse-led care provider like StellarCare NW bridges the gap.

Here, we operate differently from a standard sitting service. With nurse-led care, we view the “Hospital to Home” journey as a clinical procedure that needs management.

As our Director, Stella Shaw, and our team act with nursing oversight, we can liaise directly with the hospital discharge team. Thus, ensuring that the medication list we have matches what the hospital sent home. And if there are discrepancies, we spot them immediately, and not after a week of incorrect dosing.

👀 Spotting “Soft Signs” of Deterioration

One of the biggest passions at StellarCare is the identification of deterioration. With the recently launched CareBoodle, our carers utilise this resource that’s specifically designed to help identify delirium and other rapid changes in health.

So, to give a better insight into what we mean:
When an elderly person returns from the hospital, they are vulnerable. And a standard carer might think, “Oh, they’re just tired from the hospital stay.”

But at StellarCare, our team is trained to look deeper. We use tools and training to assess by asking ourselves: “Is this tiredness, or is this hypoactive delirium? Is their mobility worse than yesterday?”

So if let’s say we catch these issues on a Tuesday morning, we can call the GP or District Nurse immediately. But if one were to miss them, by Friday night, the client could be back in A&E.

🌟 Confidence for the Family

Now, perhaps the most important factor in preventing readmission is family confidence. That’s because when you know that a nurse-led team is visiting your loved one, checking their vitals, monitoring their wound healing, and ensuring they are hydrated, you tend to panic less.

You know that you don’t need to call 999 “just to be safe” because you have a professional sounding board to consult with. And at StellarCare, our clients’ and their families’ trust is everything to us.

🏠 Recovery Happens Best at Home

We know that people recover faster in their own environment, surrounded by their own comforts, pets and memories. And so, our job is to make that environment safe enough for recovery to happen.

If your loved one is currently in the hospital in Chester or the surrounding areas, and you’re worried about how they will cope when they return home, let’s talk.

Let us help you close the revolving door for good.