Preparing older patients to manage when they are discharged to home is a process that takes time and patience, says John Gutzwiller, BS, RN, managing consultant for Berkeley Research Group.

“Discharge teaching is often hit or miss because seniors have difficulty comprehending and retaining information,” he says.

Seniors are more likely than other patients to experience problems understanding their disease process and discharge instructions, adds Alexis S. Early, LMSW-IPR, ACM-SW, social worker for the Transitional Care program at Baylor Scott & White Health.

“Case managers and social workers should take the time to determine a patient’s healthcare literacy and present the education in a way they can understand. It’s extremely important to adapt the discharge instructions and medication education to the patient’s ability to understand them, and to follow up and reinforce the instructions after they return home,” she says.

Gutzwiller suggests that hospitals develop a disease management and navigation program to follow patients after discharge and make sure they can access the resources they need.

When elderly patients are nearing discharge, Gutzwiller advises hospital case managers to connect them with their health plan case manager.

“Every Medicare Advantage plan has case managers. When patients are in the hospital, it’s the perfect time to introduce them to someone who can follow them into the community and help them navigate the confusing healthcare system,” he says.

Another option is to refer appropriate patients to the Area Agency on Aging and its vast list of community resources, Gutzwiller suggests. “Seniors need to be connected with someone on the outside who can help them follow their discharge plan and stay out of the hospital. Being at home in a familiar setting reduces many risk factors,” he says.