Home health care and rapid rehospitalization.

Early release from the hospital of the elderly ill patient may lead to failure of the home care plan and rapid rehospitalization. Review of 330 consecutive admissions to a large urban home health agency in 1980 revealed that 43 patients (13%) were rehospitalized within 2 weeks of admission. This high risk patient population is contrasted with the average home care population in terms of living arrangements, ambulatory status, primary diagnosis, age, sex, medications, etc. Home care was probably the appropriate long-term placement if better coordination between discharge planners, PSROs, physicians and home care staff could have been established with the extension of the hospital stay by 1-2 days and/or the provision of more intensive supportive care in the home at the time of admission to the home care agency. Simple guidelines for medical/social discharge planning to provide safer transfer of ill elderly patients from hospital to home are listed.