Sylvia, a frail 87-year-old woman was recently discharged from a local hospital, after treatment for pneumonia. Her discharge instructions were the usual. She was given a plastic bag filled with prescriptions for her medications, a sheet with warning signs to be aware of and follow up appointment cards with her doctors. She was reminded to rest and stay hydrated.
Over the next several days, Sylvia remained in bed. She was too weak to go and get groceries or cook for herself. Sylvia was widowed. She had no children and her siblings were all deceased. She lived in a rather remote area and had few neighbors. She was like a growing number of seniors who are out living their family members and their support network leaving them socially isolated, alone and at risk. Sylvia was readmitted to the hospital with complications from her pneumonia only 10 days after discharge.
Unfortunately, Sylvia’s story is not unique. The need to be readmitted to a hospital after medical care or surgery is higher for those over the age of 65. In fact, one in six Medicare patients discharged from a hospital will require readmission.
Hospital readmissions not only take a toll on the overall well-being of seniors but the costs are estimated to be more than 17 billion in US dollars. In 2012, The Hospital Readmissions Reduction Program, began reducing payments to hospitals that had excessive readmissions and has forced healthcare providers to identify risks and create interventions to reduce readmissions.
One particular risk factor that has been identified is malnutrition, which occurs in up to 49% of older adults who have been recently discharged from the hospital. Moreover, those who have been diagnosed with malnutrition at the time of discharge have a higher risk for death within the year following hospitalization.
In an effort to mitigate this risk, we are currently piloting a program that will provide short term meals that are customized to meet the patient’s unique health needs, immediately upon discharge. Specifically, meals designed for patients with heart, renal or diabetic needs.
The meals will be delivered by a designated driver who will not only deliver the meals but will provide some social connection for the senior and will be trained to identify and report any medical or social risks.
As our population continues to age, social isolation continues to rise bringing with it a myriad of risks for seniors. Food insecurity is one of them. The need may be transient as seen with post-hospitalization or chronic related to declining health and limited social resources. Either way, solving for poor nutrition in our seniors is imperative.
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