Mary Holden Jones

As featured in the USA TODAY Network

One of the most severe issues facing long-term care patients is rehospitalization. Over 20% of nursing home residents are readmitted to the hospital within 30 days of discharge, a cycle that often worsens health outcomes and creates significant emotional, financial and logistical burdens for families, caregivers and the health care system.

While hospital stays are sometimes necessary, they come with added risks like hospital-acquired infections and cognitive decline, both of which harm our society's most vulnerable. The good news is that many of these rehospitalizations are preventable by integrating technology-driven solutions to reduce unnecessary hospitalizations and improve patient outcomes and quality of life.

Patients in long-term care, whether in nursing homes, assisted living or receiving palliative care, often face multiple chronic conditions, frailty, cognitive impairments and complex lists of medications. These factors make them particularly vulnerable to hospitalization. The most common causes of rehospitalization for this demographic include infections, complications from chronic health issues like heart failure or diabetes and complications related to recent surgeries. While hospital stays are sometimes necessary, they create added risks of infections and the constant back and forth can add to confusion and cognitive decline — both of which further reduce quality of life and prolong recovery times.

The emotional toll on families is equally significant. Caregivers often find themselves managing fragmented care, with multiple health care providers involved but limited communication among them. This lack of coordination can leave families feeling overwhelmed, confused and unsure about how best to help their loved one. At the same time, each rehospitalization adds financial strain, especially for families who may face out-of-pocket costs for treatments that could have been avoided.

On a broader scale, rehospitalizations also put additional pressure on hospitals, which are operating at or near capacity. The Centers for Medicare & Medicaid Services estimate that avoidable readmissions cost the U.S. health care system billions of dollars annually in emergency room visits, hospital stays and extended care.

Fortunately, many rehospitalizations are preventable with more proactive, coordinated care. Technology-driven health care solutions offer a promising way to monitor patients’ health in real time, alerting caregivers and health care providers to early signs of trouble before a minor issue becomes a major problem.

For instance, if a patient’s blood pressure rises or if signs of an infection appear, these systems can notify health care professionals immediately, enabling timely intervention. Such early detection can prevent a patient’s condition from worsening and reduce the need for hospitalization. Technology-driven solutions can also track other critical health metrics, like weight, oxygen levels and glucose readings — key indicators in managing chronic conditions and preventing emergencies.

These solutions are not intended to replace in-person care but rather complement it. Technology enhances the care provided by health care teams, allowing them to act quickly when necessary. If a monitoring system detects an issue, such as consistently high blood pressure readings, providers can adjust medications, recommend changes in diet or exercise, or initiate other treatments without waiting for an emergency. This seamless integration of technology and care helps ensure that patients receive the right interventions at the right time, preventing unnecessary hospital admissions.

Effective care coordination is another key factor in reducing rehospitalizations. Long-term care patients often require care from multiple specialists, so communication among providers is essential. By using regular check-ins, telehealth consultations and in-person rounds, nursing homes can ensure that any changes in a patient’s health are addressed promptly.

There are many technologies that already exist that allow for greater collaboration among health care professionals within the individual’s umbrella of care, allowing various charting systems to speak to one another in real time and ensuring smoother handoffs between general and specialty providers, and those working on different shifts. This coordinated approach helps to narrow the gaps in care that often lead to rehospitalizations.

In addition to better coordination among care teams, educating patients and their families is vital. With the support of technology-driven solutions, patients and caregivers can better manage medications, keep track of appointments and recognize early warning signs of illness. These tools can send reminders about medication, upcoming appointments, or changes in care plans. By empowering patients and caregivers with the information they need to manage health effectively, technology can help reduce rehospitalizations caused by missed medications, overlooked symptoms or delayed care.

Ultimately, rehospitalization in long-term care is not inevitable. With the adoption of technology-driven solutions, improved care coordination and better patient education, the cycle of rehospitalization can be broken. These solutions not only improve the quality of life for patients but also reduce the financial and emotional burdens on families.

By embracing a more proactive, data-driven approach to care, we can create a more efficient, compassionate environment for long-term care patients. By investing in these technologies, we can ensure that elderly and frail individuals receive the comprehensive care they need to thrive, while reducing unnecessary hospitalizations and improving overall health outcomes.

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Dr. Mary Holden Jones is the associate medical director of Lumina Care, one of the fastest-growing holistic and comprehensive care providers, delivering cutting-edge solutions to skilled nursing homes and community patients.