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Why Gaps in Care Exist During The Transition From Hospital to Home?



A patient gets discharged from the hospital in the hope that he has fully recovered. But what if, upon returning home, his condition worsens and he is forced to get re-admitted to the hospital? Such situations only reveal that gaps in care persist during the transition from hospital to home. 

What is the solution then to achieve a seamless transition from hospital to home with total recovery and recuperation? The use of home health care services, of course! 

Statistics of gaps in care during the transition from hospital to home 

• For all patients being discharged, the week following the hospitalization is particularly stressful. 

• 1 in 5 patients suffers from ADE-adverse drug effects or hospital complications during this period. 

• 20% of elderly Medicare patients were readmitted within 30 days. 

• Nearly 100,000 aged patients were readmitted due to ADEs. 

 Reasons for the gap in care 

 In most cases, the readmission due to gaps in care arose because 

• The patients did not feel ready to go home as their needs were not met by the healthcare providers. 

• Patients felt that they should have stayed in the hospital until their condition stabilized and the medication was working. 

• Patients with complex health issues felt the need for continuity of care even at home after their discharge from the hospital. 

 Patients did not have any familial help in continuing the care at home. In all the above cases, the patients needed home health care services in order to recover quickly from the illness and avoid readmission. It is the hospital's responsibility to recommend a certified nursing assistant with home healthcare equipment to the patient to ensure his early recovery. 

Continuity of care at home after hospitalization 

• A pilot study by Spehar, Campbell and others found that readmissions in hospitals were most for patients with heart -failure (127), pneumonia (89) or Coronary Artery Bypass.

Graft without catheterization. For such patients, home healthcare services is a must. 

• Neurological patients with complex illnesses like stroke, epilepsy, demyelinating disease need transitional care with the help of certified nursing assistants. 

• Aged patients with congestive heart failure, myocardial infarction etc. need an elderly nursing attendant with senior home care equipment. 

 Advantages of Home Health Care services 


• Even after discharge, the healthcare continues in the hands of certified nursing attendants. 

• Home healthcare providers can fully understand the health limitations of the patient and act accordingly. 

• They take all precautionary measures to ensure that the discharged patient does not suffer a relapse. 

• Home care health attendants can spot an emergency and react immediately if the patient suffers an adverse drug effect. 

• Diet, medication and health precautions for the patient are taken by the healthcare 
assistants. 

• Patients receive healthcare in the comfort and privacy of their home. 

• It is easier for the family and friends to visit the patient at home than the hospital. 

• Home Healthcare is customized to suit the individual needs of the patient. 

• It offers more independence for the patient at home than in the hospital setting. 

• Home Health Care services are more affordable than in-patient care at a hospital. 

• Pain care, wound management is done effectively by these providers. 

• Nursing attendants even offer occupational and speech therapy to the patients. 

• Home health care providers are best for providing psychological support to patients. 

Patients with chronic illnesses need home health care compulsorily to avoid relapses. Home health care services help to bridge gaps in care during the transition from hospital to home. For continuity of expert health care even after discharge, home health care services is a must. 

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