Skip to main content

Integrated Elderly Home Assistance After Hospital Discharge

  • Chapter
  • First Online:
Acute Geriatric Care: from Hospital to Territorial Charge

Abstract

In order to realize a program of hospital discharge dedicated to older people with complex needs, it is essential to guarantee certain conditions. In fact, identifying frail elderly patients after hospitalization, organizing hospital discharge taking into account all barriers such as “the bed blocker phenomenon,” and providing them with effective integrated home care (including a program of palliative care if it is necessary) may help reduce readmissions at hospital facilities, and, thus, contribute to the sustainability of care. Integrated care programs for older people living at home should include a comprehensive geriatric assessment (CGA) to increase the understanding of an older person’s care needs and preferences and to elaborate an individual care plan (PAI) at home. Health and social systems (public or private) can offer integrated home care, including home care agencies and qualified professionals who collaborate to meet the specific needs of each older patient. To achieve this model of home care after hospital discharge, in addition to the presence of a Territorial Operations Centre (defined as “COT” by the National Recovery and Resilience Plan [NRRP]) also connected with the hospital through telemedicine and digital platforms, it is essential that a formal organization is guaranteed inside and outside the hospital.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 99.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. British Geriatric Society Report. The case for more geriatricians. A workforce to care for the ageing population. 2022. https://www.bgs.org.uk/BGScallsformoregeriatricians.

  2. McMartin K. Discharge planning in chronic conditions: an evidence-based analysis. Ont Health Technol Assess Ser. 2013;13(4):1–72.

    PubMed  PubMed Central  Google Scholar 

  3. Al Ghassani A, Rababa M. Factors associated with home care outcomes among community-dwelling older adult patients with dementia. Dement Geriatr Cogn Dis Extra. 2021;11(2):99–109. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215980.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Boaz TL, Becker MA, Andel R, McCutchan N. Rehospitalization risk factors for psychiatric treatment among elderly Medicaid beneficiaries following hospitalization for a physical health condition. Aging Ment Health. 2017;213:297–303.

    Article  Google Scholar 

  5. Pellico-López A, Cantarero D, Fernández-Feito A, Parás-Bravo P, de Las C, Cuevas J, Paz-Zulueta M. Factors associated with bed-blocking at a university hospital (Cantabria, Spain) between 2007 and 2015: a retrospective observational study. Int J Environ Res Public Health. 2019;16(18):3304. https://www.mdpi.com/1660-4601/16/18/3304.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Schlepper L, Dodsworth E, Scobie S. Understanding delays in hospital discharge: Nuffield Trust QualityWatch Blog. 2023. www.nuffieldtrust.org.uk/news-item/understanding-delays-in-hospital-discharge. Accessed 28 Apr 2023.

  7. Stoop A, Lette M, van Gils PF, Nijpels G, Baan CA, de Bruin SR. Comprehensive geriatric assessments in integrated care programs for older people living at home: a scoping review. Health Soc Care Community. 2019;27(5):e549–66. https://onlinelibrary.wiley.com/doi/10.1111/hsc.12793.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Hengartner MP, Klauser M, Heim G, Passalacqua S, Andreae A, Rössler W, et al. Introduction of a psychosocial post-discharge intervention program aimed at reducing psychiatric rehospitalization rates and at improving mental health and functioning. Perspect Psychiatr Care. 2017;531:10–5.

    Article  Google Scholar 

  9. Clotworthy A, Kusumastuti S, Westendorp RGJ. Reablement through time and space: a scoping review of how the concept of ‘reablement’ for older people has been defined and operationalised. BMC Geriatr. 2021;21(1):61.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Mishra V, Barratt J. Reablement and older people. 2016. http://www.ifa-copenhagen-summit.com/wp-content/uploads/2016/04/Copenhagen-Summit-Final-Report.pdf.

  11. Zurlo A, Zuliani G. Management of care transition and hospital discharge. Aging Clin Exp Res. 2018;30(3):263–70. https://link.springer.com/article/10.1007/s40520-017-0885-6.

    Article  PubMed  Google Scholar 

  12. 2004 JCAHO National Patient Safety Goals approved. Jt Comm Perspect. 2003;23(9):1, 3.

    Google Scholar 

  13. Rubin SG, Davies GH. Bed blocking by elderly patients in general-hospital wards. Age Ageing. 1975;4(3):142–7. https://doi.org/10.1093/ageing/4.3.142.

    Article  CAS  PubMed  Google Scholar 

  14. Pellico-López A, Fernández-Feito A, Cantarero D, Herrero-Montes M, Cayón-De Las Cuevas J, Parás-Bravo P, Paz-Zulueta M. Delayed discharge for non-clinical reasons in hip procedures: differential characteristics and opportunity cost. Int J Environ Res Public Health. 2021;18(17):9407. https://www.mdpi.com/1660-4601/18/17/9407.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Pellico-López A, Fernández-Feito A, Cantarero D, Herrero-Montes M, Cayón-de Las Cuevas J, Parás-Bravo P, Paz-Zulueta M. Cost of stay and characteristics of patients with stroke and delayed discharge for non-clinical reasons. Sci Rep. 2022;12(1):10854. https://www.nature.com/articles/s41598-022-14502-5.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

The authors would like to thank the geriatricians of Cognitive Disorders and Dementia Unit—Health Authority and Services of Modena who collaborated to realize this chapter: Lucia Bergamini, Barbara Manni, Marina Turci, and Antonella Vaccina.

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Vargas, N., Fabbo, A., Esquinas, A.M. (2023). Integrated Elderly Home Assistance After Hospital Discharge. In: Acute Geriatric Care: from Hospital to Territorial Charge. Springer, Cham. https://doi.org/10.1007/978-3-031-48813-9_11

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-48813-9_11

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-48812-2

  • Online ISBN: 978-3-031-48813-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics