Family matters | How to avoid the hospital revolving door syndrome

A woman who lives on the East Coast recently called Jewish Family and Children’s Services of the East Bay with concerns about her 84-year-old mother. The mother, who lives in the Bay Area, was hospitalized locally and was possibly going to be discharged to a rehabilitation facility before returning home. The daughter was concerned because she could not oversee her mother’s care directly through these complicated steps and was worried that her mother would end up back in the hospital.

When an illness strikes that requires treatment in a hospital setting, many older adults and their family members are challenged by the same issue this woman faced: how to provide for a smooth transition out of the hospital, in order to prevent readmission.

As family members, we are concerned about our loved one’s continued quality of life — which is partially dependent on proper medical management and social support after discharge. Repeat hospital stays put older adults at higher risk of bedsores, delirium and hospital-acquired infections. These are all important reasons to prevent being in the hospital longer than one’s condition requires.

Preventing rehospitalizations is also an important topic of concern for the health care industry. Readmission rates for those 65 and older within 30 days of hospital discharge are currently receiving much scrutiny from Medicare. According to the Dartmouth Atlas Report on Hospital Readmission in Medicare Beneficiaries, one in five elderly patients is back in the hospital within 30 days. The federal government estimates that $17 billion is spent on return trips that would not have happened had the patients received the care they needed during this delicate transition period. The Centers for Medicare and Medicaid Services actually penalizes hospitals with high rates of readmissions for certain conditions, such as heart failure, heart attack and pneumonia.

The hospital discharge process can be a flurry of activity with multiple sets of instructions on follow-up appointments, special care needs, equipment rentals, dietary considerations and new medications. This complexity has the potential to result in poor outcomes. Some contributing factors are breakdowns in communication between medical providers, inadequate patient and caregiver education, poor continuity of care, complicated instructions for care and limited access to services, sometimes due to transportation barriers. Family members frequently are not included in discharge planning, even though they may be the patient’s primary caregivers. Accountability for the discharge process is scattered among hospital staff, community physicians, nurses, skilled nursing facilities and families.

Additionally, discharges are happening more after shorter hospital stays, which means patients are often leaving the hospital before they are fully ready to begin recuperating. Sometimes patients who have experienced cognitive changes are discharged too early, without proper supports in place to address their new condition.

As family members, what can we do to protect our loved ones and ensure they get proper care as they leave the hospital? Asking questions, advocating and being our own care coordinators is the ideal situation, but many of us simply can’t do this on our own. We may live far away, and we often don’t have the right medical knowledge. And we may not know where to turn for all the types of support our loved ones need.

Some health systems are now using transitional care models. These involve teams of professionals including social workers and nurse case managers that guide a family through their post-hospital needs. Inquire at your hospital or rehab facility to see if this is an option for you.

Another fee-based option is a geriatric care manager who can be an advocate and a care coordinator. This professional can be hired by the older adult or family member before discharge. (Most Jewish Family and Children’s Services agencies across the country have care management programs. You can also contact the National Association of Professional Geriatric Care Managers at for information.)

Care managers and transitional teams intervene on multiple levels to assist patients as they leave the hospital. They assess the patient’s needs, set up services prior to discharge, oversee discharge instructions, arrange transportation, follow up with physicians, assess for caregiver burden, place and oversee in-home care if needed, and involve the primary care physician and pharmcist in medication management. Assessment continues once the older adult is at home, including evaluating mental health changes and social support.

This monitoring and consistent professional presence enhances safety in the home and improves quality of life after a challenging period of illness.

Most important, it also helps ensure that older adults get the care they need once they leave the hospital, thereby avoiding the “hospital revolving door” syndrome.


Rita Clancy, LCSW, is the interim director of Adult Services at Jewish Family and Children’s Services of the East Bay. Her columns appear regularly in J.’s Seniors sections. Have questions about your aging parents? Email [email protected] or call (510) 558-7800 ext. 257.

Rita Clancy
Rita Clancy

Rita Clancy, LCSW, is the director of adult services at Jewish Family & Community Services of the East Bay. Have questions about your aging parents? Email [email protected].