Article Archive
January/February 2020

Long Term Care: In-Home Caregivers — Supporting the Transition Home
By Kerin Zuger
Today’s Geriatric Medicine
Vol. 13 No. 1 P. 30

“I want to live at home as long as possible.” What started as a wish by patients has become a demand as more and more older adults choose to live at home for as long as they possibly can.

Nearly 70% of Americans who reach 65 years of age will be unable to care for themselves at some point in their future without assistance.1 This is largely because Americans are living longer than ever and are experiencing multiple chronic conditions such as diabetes and dementia, as well as a range of functional impairments. These factors, combined with the possible financial penalties hospitals and health systems face under Medicare’s Hospital Readmission Reduction Program, put more pressure on providers to fill any potential gaps in a patient’s continuum of care.

For fiscal year 2019, the Centers for Medicare & Medicaid Services made a change to adjust the distribution of penalties among participating hospitals. However, even with the adjustment, more than 75% of hospitals still fell within penalty status.2 Hospitals and health systems need to continue to address the continuum of care in an effort to lower readmissions.

Many older adults and their providers have looked to family members to fill the need for in-home caregivers. Having a child or another family member serve in this role is seldom an option today, as there are fewer family members to help and many have full-time jobs outside the home. And because technology makes it easier for families to stay connected and yet live even farther apart, patients may have fewer relatives nearby who can assist them. Today, the ratio of family caregivers to older adults is 7:1, but by 2050, this number will shrink by more than half to 3:1.3 People older than 65 outnumber those younger than 5 years old, and within the next several months, the population of older Americans will exceed 56 million.4 Clearly, the need for assisted care to effectively support the desire of older adults to live in their homes as long as possible is greater than can be met by family members.

Having the right preventive care measures in the home is critical to keeping older patients out of the hospital. However, it’s equally important that families determine effective transitional care plans should the patients require admission to a hospital. Among the top reasons for hospital readmissions is failure to follow a care plan. This could include anything from not making follow-up appointments to missing medications or not paying attention to proper hydration—all things that are avoidable when in-home care is included in the transitional care plan. Trained in-home caregivers can provide patients with a near-perfect balance of care plan compliance and companionship.

Forsyth Medical Center in Winston-Salem, North Carolina, conducted a transitional care study that focused on frail elderly patients with complex social and medical needs. A patient navigator and in-home care immediately after discharge provided the patients with extended social support and health education while keeping more patients at home, reducing readmission rates by 61%.5

Professional in-home caregivers bridge communication gaps between patients, their families, and providers. They hear and understand discharge instructions and support clinicians in helping patients fully comprehend what they need to do following their hospital stays. In addition to having a better understanding of providers’ instructions, these professionals are also trained to look for and report any sign of declining health or changes in condition. From weakened muscles to cognitive struggles, they’re in a position to respond quickly and communicate any concerns from medical teams.

When a change in condition that could increase a patient’s fall risk is identified, timely communication with the health care team is especially important. Falls are one of the most common causes for readmission. According to the Centers for Disease Control and Prevention, roughly $50 billion was spent on nonfatal falls in 2015, about $29 billion of which is paid by Medicare.6 In-home caregivers can help prevent falls, specifically during those crucial 30 days following discharge, saving hospitals and health systems from costly penalties.

Professional in-home caregivers also ensure consistency in medication use and therapeutic ambulation. This benefit begins immediately upon discharge, as they make sure medications are filled right away and taken as prescribed. Without assistance, many older adults forget to take their medications properly or fail to take them altogether. Regardless of the reason for noncompliance, failure to take medications as prescribed can result in readmission. Similarly, older patients with no care or undersupervised care are unlikely to follow the physical rehabilitation protocol their physicians prescribe. When supported in their physical activity by in-home caregivers, whether through at-home therapies or simply guidance walking and moving to build strength, older adults are more likely to return to the level of health they experienced prior to hospitalization, or nearly so.

In a study to determine whether the implementation of community-based, patient-centered social support could affect the reduction of avoidable readmissions, Lexington Medical Center saw a total readmission reduction of 17%.7 The study shows social determinants of health for older adults should be part of the conversation among providers, patients, and their families. Where patients live, their ages, and their routines play a role in how quickly and effectively they’re able to heal. A few questions to consider in regard to social determinants and quality of life include the following:

• How available are resources to meet daily needs such as safe housing, fresh water, and healthy food?

• Does the patient have access to health care services?

• Do community-based resources that promote social engagement exist in proximity to the patient’s neighborhood?

• What are the patient’s transportation options?

According to the American Geriatrics Society, driving skills generally start to fade after age 75, but that deterioration can really begin as early as age 60. Slowing reflexes, chronic diseases, and certain medications further interfere with individuals’ ability to drive or travel independently in order to access the resources they need to sustain their quality of life. Professional in-home caregivers positively influence patients’ social and physical environments. Being immersed in a patients’ social and physical environments allows these caregivers to fully see and understand possible barriers to success. They’re able to ensure older adults take medications as directed, provide transportation to appointments and social engagements, make sure regular healthful meals that adhere to any dietary restrictions are readily available, and offer companionship and support.

Finally, successful outcomes can be achieved sooner with the assistance of trained in-home caregivers. They provide personalized care for the whole person. This includes preparing meals that meet any dietary restrictions, helping seniors stay involved socially, and offering support in daily tasks such as household chores and personal hygiene. Home care empowers older adults to live as independently as possible and relieves family members of the burden of providing care or moving closer to home. Furthermore, when older adults are able to live as they choose, they’re more likely to be engaged in their care and focused on achieving sustainable levels of health.

Today, in-home caregivers become an extension of a provider’s team, as it truly takes a village. Their involvement can give providers greater insight into how well patients are healing and progressing toward a better quality of life. Having a trained set of eyes and ears on older patients can greatly reduce readmissions and improve patient satisfaction rates, ultimately saving hospitals costs of readmission penalties and protecting their reputations. Having this resource available makes it easier for providers to eliminate gaps in care and give older patients what they really want: to live at home as long as possible.

— Kerin Zuger is the senior vice president of strategic growth and innovations for Right at Home ( Zuger leads efforts around building collaborative partnerships in health care, while finding innovative and synergistic ways to grow and diversify revenue streams.


1. Daschle T, Thompson T. Who will care for America’s aging population? The Washington Post. November 21, 2013.

2. McCarthy CP, Vaduganathan M, Patel KV, et al. Association of the new peer group-stratified method with the reclassification of penalty status in the Hospital Readmission Reduction Program. JAMA Netw Open. 2019;2(4):e192987.

3. Joint Center for Housing Studies of Harvard University. Housing America’s older adults — meeting the needs of an aging population.
. Published 2014.

4. Home Care Association of America, Global Coalition on Aging. Caring for America’s seniors: the value of home care. Published 2016. Accessed October 17, 2019.

5. Watkins L, Hall C, Kring D. Hospital to home: a transition program for frail adults. Prof Case Manag. 2012;17(3):117-123.

6. Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C. Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc. 2018;66(4):693-698.

7. Holly R. Right at Home helps Lexington Medical slash its readmission rate. Home Health Care News website. Published March 21, 2019.