Health care systems are doing more to shorten hospital stays and prevent re-admissions for patients once they get out.
It's a troubling fact that of the millions of seniors hospitalized every year, "20% of all Medicare patients get re-admitted to the hospital within 30 days," said Dr. Heidi Syropoulos of Independence Blue Cross.
Dr. Syropoulos says the reasons vary. Perhaps the patient just wasn't ready to go, or there were complications or drug reactions which didn't show up in the hospital.
But often, the causes were preventable such as, not following or even understanding the hospital's care instructions. Or not enough support at home to help the patient's recovery.
Health care systems are under orders to reduce re-admissions, or face cuts in Medicare reimbursements. So, They've become more proactive.
Dr. Syropoulos said, "Discharge planning should start the day you arrive at the hospital."
At Nazareth Hospital in Northeast Philadelphia, that goes to Dr. Genevieve Skalak. She's a new medical specialist - an "extensivist."
"I provide that bridge between the inpatient hospital stay and their outpatient path to wellness," she said.
Dr. Skalak focuses on patients most likely to come back - those with multiple chronic ailments, like diabetes, heart failure, or COPD.
"What got them there in the first place, what do they need to get well again, and where are they headed after the hospital stay?" said Dr. Skalak.
Primary care doctors are also notified to help patients follow those plans.
One study shows 'extensivists' can cut hospital stays by almost half, and re-admission rates by nearly 20%.
Whenever you leave a hospital, you always need a discharge summary, and "patient instructions."
Dr. Syropoulos said, "It has to be written in your language, it has to be written in language you can understand."
She says go over it thoroughly with a family member, and follow it.
"It decreases all that pain and suffering of having to go back into the hospital," said Dr. Syropoulos.
And don't be afraid to ask what's going on with your discharge even while you're in the hospital.
"You should, every day if you want to, speak to a nurse and say - what's happening with my discharge planning? I'd like to be part of that, if I can," says Dr. Syropoulos.
She urges patients and loved ones to take advantage of the case managers and social workers hospitals have, to help you navigate the system.
"Ask for help. If the discharge papers say. 'We want you to follow-up with Dr. Jones in a week," find out- 'Can someone make that appointment for me?'
She continues, "If they can't, make sure some of your family members can do that."
Another key piece of advice - After you leave the hospital, "Bring your patient instructions to your primary care doctor when you see him."
Dr. Syropoulos says, "Sometimes the primary care doctor hasn't received the discharge summary yet, or they don't even know you've been in the hospital."
You may be holding the only copy of that vital information to guide your road back to better health.
If you're confused about instructions or having difficulty navigating the hospital's system, call your insurance company's customer service line.
"Often, Medicare Advantage plans have case managers or health coaches that can contact them to easily to help get records, get you coordinated, even get you appointments with primary care doctor."
"There's a lot more help out there than many realize!" she notes.
Follow this link to the Independence Blue Cross Medicare Member Help Team.
For more information on other senior programs, click here for the Art of Aging section.