Just this week, I heard about someone being discharged from Asante Ashland Community Hospital. Their friend wanted to be sure they knew what to keep in mind, in order to stay out of the hospital in the near future. It’s good to have this information. The newer Medicare rules state that if you return to the hospital within 30 days for the same medical condition, it’s possible that Medicare will not pay for this second hospital stay. With so many changes to Medicare, it’s really important to know how to maximize your chances of not being readmitted.

In 2011, The National Transitions of Care Coalition put together an evidence-based report of seven key elements, based on transition intervention research. I’ve summarized them here for you. The person you can rely on for this guidance and support before leaving Asante Ashland Community Hospital is the discharge planning nurse, currently Athera DeAngeles.

Here then are the seven tasks to keep in mind when going home:

Task 1: Medication Management: You’ll want to come up with a method to ensure the safe use of medications, based on the person’s care needs. Someone has to be monitoring this accurately. This might be a good reason to call one of the caregiving agencies that can provide this service.

Task 2: Transition Planning: This is a process that facilitates the safe transition from one care setting to another, or from one practitioner to another. Basically this means planning for what you might need in order to go safely from hospital to home, or to another care facility, as well as any follow up with a physician besides your usual provider.

Task 3: Patient and Family Engagement/Education: This hopefully means a family meeting in the hospital. You would be amazed at how often this does not happen. Once someone is out of the hospital, it’s difficult to get a plan in place without good medical information. Knowing who is going to do what task is vital. How does family living in the Bay Area stay involved, for instance?

Task 4: Information Transfer: Sharing of important care information among family, caregiver, and health care providers in a timely and effective manner is so important. This is where you often see all the cracks in the system. Do not assume that one doctor knows what another one has ordered or what the treatment plan might be.

Task 5: Follow–Up Care: This covers facilitating the safe transition from one care setting or care provider to another through effective follow-up activities. This is not the same as planning for the transition — it’s making sure that it was the right fit afterwards and that all is in place. If adjustments need to happen, who is in charge of this?

Task 6: Health Care Provider Engagement: I cannot tell you how many times it seems that the medical providers are out of the loop and it’s hard to get them involved. Here is where you need someone to connect the dots with and between providers — and be a strong advocate.

Task 7: Shared Accountability across Providers and Organizations: The transition process has to include accountability for the person between the healthcare provider (like the hospital) and the one receiving them (like skilled nursing). To me this means no one gets to pass the buck and each organization has a part to play. No provider or organization can just drop the ball or point a finger at the other.

Most people can’t wait to get out of the hospital. Not everyone can safely go back to their usual home after hospitalization though, even with in-home caregivers. Many people do need to be in rehabilitation or skilled nursing. Another option is to be discharged to an adult foster care home. These facilities will make sure that each of these seven tasks are fully addressed. They have an excellent track record of keeping their residents out of the hospital as much as possible. A professional care manager can also coordinate this transition on your behalf. All the discharge planners at the hospitals know about and utilize these options as well.

Hopefully, you will not face this situation, but knowing how the system works can help you prepare ahead of time. Staying out of the hospital is a worthy goal. But if you are hospitalized, knowing how to improve your odds of not being re-admitted can be a huge relief.

Ellen Waldman is a certified geriatric care manager. Email questions about aging and Ashland-area aging resources and column suggestions to her at edw@ashlandhome.net.