To describe and see the needs for the most sick of the elderly with a follow-up at home after being discharged from the hospital – contact the patient within 48-72 hours.

Method

The data was collected by using a questionnaire, answered by the patient and a nurse. The interviews were made either by the phone or during a home visit. The nurse then faxed the answer to the coordinator at the hospital. The response rate was 65 %. The results were analyzed using descriptive statistics.

Results

The primary care had the most follow-ups over the phone and the community care did the most follow-ups with a home visit. Patients with readmission more than two times in six months were 65%. In 85% the medicine list was sent with the patient after discharge, however 45% of the home visits were to correct, change and help patient with the medicines. The department for most sick of the elderly (MÄVA) was the department with the majority of the home visits after discharge.

Conclusion

A follow-up with telephone or home visit after discharge from hospital creates a safety for the most sick of the elderly but also an extra checkup of the patient in the home environment. Cooperation between the hospital, the primary care and the municipality must work in the most optimal way so the patient does not get exposed to unnecessary suffering. Readmission of the most sick of the elderly is difficult to reduce because of their complex need of care.