Caring for the Caregiver: How nurses can help caregivers prepare to deliver better post-acute care to loved ones


Heather O’Sullivan

Chief Clinical Officer, naviHealth, a Cardinal Health company

As the shift to value-based care becomes increasingly prevalent, hospitals are seeking new ways to improve patient outcomes through the patient’s post-acute journey.

With an aging population, more and more middle-aged adults are naturally becoming caregivers for their parents and are often guiding what happens once they leave the hospital.  Overwhelmed by multiple responsibilities, and under-equipped to deliver the kind of care their parents require, this “sandwich generation” seeks guidance for taking on the responsibilities of caring and planning for a loved one with new healthcare needs. Finding time to provide this guidance can be challenging for healthcare providers, particularly as acute lengths of stay are becoming shorter, leaving an increasingly smaller window of time for caregiver planning and education before discharge.

Further complicating matters is the fact that there is no one consistent process, place, or person to help educate caregivers so they can coordinate post-acute care – leaving a void that can negatively impact both patients and providers.

Research shows that one in five Medicare enrollees is readmitted to the hospital within 30 days, and up to 75% of these readmissions are preventable.1 Research also demonstrates that both 30-day and 60-day readmissions can be reduced when patients or their caregivers are educated about post-acute care options, and when a care transition plan is in place to ensure the patient has the appropriate level of care for the right duration.2

In many healthcare settings, social workers are an excellent resource for families who need this kind of support and guidance. However, social workers are often only utilized for the most complex cases.

That’s why acute care nurses are in many ways ideally positioned to help encourage and prepare caregivers to serve as an extension of the care team.  Caregivers can help to ensure medication adherence and reduce the chance of a readmission.

The nurse-caregiver connection

Why are nurses well positioned for this role? First, patients and caregivers often develop a personal rapport with nurses. After all, they are often the healthcare providers with whom patients and families spend the most time during hospital stays. Second, nurses are highly credible – consistently ranking either #1 or #2 in Gallup’s annual poll, which asks consumers which healthcare providers they trust the most. And third, acute care nurses are already playing a role in extending support beyond the hospital with the help of emerging solutions like naviHealth. Solutions like naviHealth equip nurses to help determine optimal post-acute care settings, and to begin the planning process with caregivers for a myriad of new non-medical care needs.

Today’s ‘sandwich generation’ of caregivers is in desperate need of encouragement, resources and support – before their loved ones leave the hospital. Consider this:

  • Fifty nine percent of patients receiving unpaid care from a loved one are coping with a long-term physical condition; 26% are dealing with memory problems and 37% are dealing with more than one ongoing problem or illness. 3
  • On average, caregivers spend 24.4 hours a week providing some type of post-acute care to a loved one; and one-fourth provide 41 or more hours of care each week – often while also holding down jobs to support their families. 3
  • Post-acute care can be complex – more than half (53%) of care recipients have been hospitalized in the past 12 months. Sixty percent of caregivers perform medical tasks normally performed by a nurse, including things like injections, tube feedings, catheter and colostomy care. And only 14% indicate that they have received preparation or training to do so. 3

Empowering caregivers and the demystification of the post-acute care planning process

Caregiver resources

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The caregiver often takes the lead when it comes to pulling together a plan for home and community based services. This can be an overwhelming and complicated burden, especially for those with no healthcare experience. If we aid acute care nurses with technology, support tools and processes that incorporate post-discharge planning early into a patient’s hospital stay, they can help reduce this burden.  Nurses can connect caregivers with key resources to simplify and demystify the post-acute care planning process. Resources may vary in each community, and based on patient need – but a handful of resource examples include:

  • Family caregiver guides which help caregivers better understand the healthcare landscape, assess where their loved one can go as their next step in care, what questions they need to ask physicians, and more.
  • State Area Agencies on Aging (or “Triple As”), whose sole purpose is to build the capacity of caregivers and communities to help older adults and people with disabilities live with dignity and choices, for as long as possible. Caregivers can easily find their local AAAhere, but nurses can help facilitate this connection by making caregivers aware of the broad suite of services they offer – services that improve the quality of life of patient and caregiver alike.
  • Planning technologies like which reduce caregiver time and burden by making it easier to organize support from family, neighbors and friends to prepare and deliver meals, provide transportation to medical visits or take turns checking in on or caring for the patient when the caregiver needs additional coverage. These technologies can also make it easier and less time consuming for caregivers to provide health status updates to family and friends.
  • Medication synchronization tools that help patients manage complicated medication regimens – helping to make sure patients take the right medications, at the right dose, at the right time. Many of these tools can also reduce caregiver burden by consolidating the number and frequency of visits a caregiver needs to make to a pharmacy.
  • Home delivery services for medical supplies – like, which can ensure caregivers have consistent, convenient access to the broad range of hospital-quality products ranging from catheters and feeding tubes to durable medical equipment – which they need to deliver safe, effective care at home. 
  • National support organizations, like the National Alliance for Caregiving and theCaregiver Action Network which are dedicated to improving the quality of life for caregivers. These groups often share practical information that can help caregivers prepare for and better cope with the added responsibilities of caring for a loved one.
  • Specialized advocacy, through finding a social worker or leaning on an organization likeAlzheimer’s Association, both of which can help caregivers better understand the unique challenges that they and their loved one will face, while also providing specialized tools and resources that address needs that are specific to the health issue(s) that the patient is facing.

Well trusted by and in frequent contact with patients and caregivers, acute care nurses are well positioned to connect caregivers with resources and support tools for successful post-discharge care. In doing so, nurses can help hospitals improve patient satisfaction, reduce preventable readmissions and contribute to positive, long term outcomes for patients.

Editor’s Note: Cardinal Health is dedicated to caregivers. This is one of a variety of articles we will share to address the importance of caregivers and ways to support them.


1 Nelson, Joan, DNP, ANP-BC and Pulley, Amy L., BA, “Transitional care can reduce hospital readmissions,” American Nurse Today, April 2015 Vol. 10 No. 4
2 Bowles et al, “Successful electronic implementation of discharge referral decision support has a positive impact on 30- and 60-day readmissions,” Research Nursing Health, January 2015
3 National Alliance for Caregiving, Caregiving in the U.S., 2015