Hospital readmissions can be distressing, especially for seniors. They often signal a lack of comprehensive care and support, leading to a vicious cycle of health setbacks. Nearly 1 in 5 Medicare patients are readmitted to the hospital within 30 days of discharge, according to the Centers for Medicare and Medicaid Services. This issue is costly, dangerous, and often preventable with the right senior care.

As an Aging Life Care Manager, my goal is to help seniors stay healthy and independent so they can avoid unnecessary trips to the hospital. Here’s how we do it:

Transition Support After Discharge

The transition home after a hospital stay is risky. Seniors are still recovering, have complicated medication regimens, and require follow-up appointments. Without proper support, they can easily get confused or overwhelmed. As Aging Life Care Managers, we ensure our clients have everything they need to transition home safely. This includes coordinating home health services, providing transportation, explaining discharge instructions, and more. Having a guide through the transition reduces the chances of complications that lead to readmission.

Ongoing Care Management

Simply surviving the hospital discharge is not enough. Seniors need consistent support to remain healthy at home. As Aging Life Care Managers, we provide ongoing care management for our clients. This includes medication management, coordinating medical appointments, providing referrals to health services, and continually monitoring my client’s condition. By staying involved, we can detect early warning signs and address issues before they escalate into an emergency.

Advocacy and Care Coordination with Healthcare Providers

Navigating healthcare as a senior is complicated. With multiple specialists and complex conditions, things can fall through the cracks. As Aging Life Care Managers, we act as advocates and care coordinators with my client’s healthcare providers. I make sure care is coordinated between specialists to avoid conflicts. I also accompany clients to appointments to help explain symptoms, ask questions, and ensure all instructions are clear. This oversight helps prevent medical issues from being overlooked.

Family Education and End-of-Life Care Planning

Aging Life Care Managers educate families on how to best support their senior loved ones. This includes recognizing signs of health deterioration and taking preventative measures to keep seniors out of the hospital. For seniors with advanced illnesses, Aging Life Care Managers assist in making end-of-life plans that align with the seniors’ wishes, preventing unnecessary, distressing hospitalizations in favor of compassionate, home-based care.

Remember, the key to preventing hospital readmissions is proactive, personalized care. With Aging Life Care Managers by your side, you can ensure your senior loved ones receive the support and attention they need to stay healthy and avoid the revolving door of hospital admissions.

How to Find an Aging Life Care Manager

If you or a loved one could benefit from this type of senior care management, we at Complete Care Strategies provide these services to older adults in the Greater Philadelphia Region out to Lancaster County, South Jersey, and Northern Delaware and can be reached at 610-265-4300. Our goal is to help seniors remain independent and healthy in their own homes. Reach out today to learn more about my services. Or you can search for an Aging Life Care Manager in your area through

About the Author

As CEO of Complete Care Strategies, Rebecca Roskey-Brunner leverages over 20 years of experience as a Registered Nurse and Certified Care Manager to serve clients with special needs, the medically complex, and older adults facing health challenges to improve their quality of life. As an Aging Life Care Professional, Rebecca brings deep expertise in individualized care planning, dementia care, care coordination, and crisis prevention for vulnerable seniors.