A program in the Chicago area is demonstrating the value of tailoring discharge plans to the particular needs of elderly patients with little support outside the hospital.

These “solo seniors” often face complex medical challenges after discharge and can experience high rates of readmission without help from family and friends. With hospitals facing significant penalties from 30-day readmissions, the program could be a model for hospitals to emulate.

Seniors Alone Guardianship & Advocacy Services is a not-for-profit program that works with Chicago-area hospitals to closely monitor elderly patients after their release from the hospital.

The group helps spot health issues as they arise and see that patients are treated before these issues become serious enough to require readmission.

The advocates supervise post-discharge care to ensure patients are receiving what they need, whether in a skilled care facility or receiving care at home, explains Founder and Board Chair Teri Dreher, RN, CCRN, iRNPA, who left hospital nursing after 40 years as an intensive care nurse.

In addition to the seniors program, she also is chief advocate and president of North Shore Patient Advocates, a Chicago company that provides assistance to patients who need help navigating the healthcare system. Dreher was inspired to form Seniors Alone as a result of the struggling “senior orphans” she has met through her advocacy business. She notes that one out of every four seniors in Illinois must face healthcare challenges alone while surviving on less than $20,000 per year. The Seniors Alone assistance is particularly important for medically complex patients, which many seniors are, Dreher notes.

The Seniors Alone team includes experienced nurses, social workers, care managers, attorneys, and guardians. They work with healthcare providers, courts, and long-term care resources to ensure patients receive appropriate care.

If a hospital called on the program to assist with the discharge plan for a solo senior with a broken hip, the team would choose the rehabilitation facility and make post-rehab living arrangements, Dreher explains. This would include finding a skilled care facility or home healthcare agency, coordinating with Medicare and Medicaid, and monitoring the patient’s ongoing health.

Seniors Alone’s fees are assessed on a sliding scale, based on the client’s ability to pay. The client readmission rate for Dreher’s patient advocacy company has stayed under 1% for the last eight years, and she hopes to maintain the same rate for the not-for-profit Seniors Alone.

The American Hospital Association (AHA) reports that almost 20% of Medicare beneficiaries return for readmission within 30 days of discharge. Further, each readmission of a senior patient costs the hospital an average of $7,400.1 The AHA profiled a program at Rush University Medical Center in Chicago that focuses on the post-discharge needs of seniors.1

Staff from the hospital’s older adult programs and case management department created the Enhanced Discharge Planning Program in which social workers call senior patients after discharge to check on compliance with their discharge plans. The social workers also look for unmet needs and facilitate solutions to meet those needs.

In a pilot program on four units, the social workers found 67% of discharged senior patients were not receiving necessary services, following discharge recommendations, or coping with care demands.1 Hospitals are interested in this type of support because many do not have the resources to provide this kind of support to solo seniors, even though they realize those patients can be in jeopardy after discharge, Dreher says. She encourages hospitals to consider developing similar programs because the need is significant — and so are the potential benefits.

“There are an awful lot of bad skilled nursing facilities, bad home care companies, and a lot of home care companies are going out of business because of new Medicaid guidelines,” Dreher says.

“For seniors who don’t have family to be their caregivers, they are really falling through the cracks, especially if they are starting to have cognitive issues,” she continues. “They don’t have someone to check on their medications, to oversee the care they’re receiving from the skilled nursing facility or home care provider. You end up with them being readmitted to your hospital unnecessarily.”

Addressing solo seniors with a post-discharge program can help reduce 30-day readmissions, improve patient engagement, boost patient compliance, and shorten hospital stays by helping families pick out a reliable rehab facility or home care company, Dreher says. “To us, it’s a social justice issue. This country doesn’t have a great way to take care of our seniors. With 10,000 people turning 65 every day, hospitals that can figure out how to best provide care management for these seniors without any support will serve their community better and reap benefits of their own, too,” Dreher says.

“Hospitals sometimes keep patients for a week or two because they have no safe discharge plan, creating a pain point for the hospital that results in additional costs and burdens on your resources,” she adds.

The costs for such a program, in-house or from an outside provider, should be offset by the savings in avoiding Medicare penalties for excessive readmissions and other losses that can come from treating solo seniors, Dreher says.

“Plus, [hospitals] have to carry the expense for the extended hospital stay of patients who are medically stable but can’t be discharged without an adequate plan. They’re sitting in a hospital bed that costs $3,000 to $4,000 a day,” Dreher says. “When the insurance companies and Medicare say they’re not paying for more days, the hospital administration is stuck. It costs too much money to keep them, but you don’t want to discharge them and see them come back for readmission within a month.”

Dreher says quality professionals can make a business case for providing special discharge planning for solo seniors, in addition to the improvement in community support for a vulnerable population.

“We can do it because it’s the right thing to do for these senior patients who don’t deserve to be left on their own at this time in their lives. But there’s no doubt that hospitals will see a benefit to the bottom line as well,” Dreher says.


  1. American Hospital Association. Social workers enhance post-discharge care for seniors. Available at: http://bit.ly/312VDJJ.