"Discharged but Struggling with Meals and Cleaning... Home Care Workers Saved Me Again"[Turning My Home into a Senior House]

"I'll follow the discharged elderly home"
For elderly living alone, discharge is scarier than injury
At the crossroads of recovery or deterioration:
The 'golden time' right after discharge
Consulting with hospitalized seniors in advance,
Following them home after discharge to provide daily support and medical care

Grandmother Lee Jeong-sook is having lunch with the help of a home care worker at her home in Jincheon-gun, Chungbuk Province, on the afternoon of November 5 last year. Photo by Kang Jin-hyung

"I was more afraid of being discharged than getting hurt"

Grandmother Lee Jeong-sook (92), who lives on Jangteo-gil in Jincheon-gun, Chungcheongbuk-do, gazed quietly at the lunch tray brought into her room by the home care worker, recalling a year ago. In November 2023, she twisted the area below her chest and collapsed while getting up from the dining table. She was immediately taken by a 119 ambulance to Jungang Jeil Hospital in Jincheon town and underwent rib surgery.

While in the hospital, aside from the pain, she had no discomfort. The doctor checked her condition daily, and she had every meal in bed. However, the problem began after discharge. Managing medication and meals became entirely her responsibility.

"I thought I would surely die if I went home like that. But when I was discharged, the nurse came to me and asked if there was anyone to take care of me at home. I told her I lived alone. I wondered how I would manage at home, but the county office sent a home care worker. She comes every day for three hours, prepares meals, and cleans. Since I can't even think about going to the hospital myself, the nurse also visits my home once a week."

'Can I live in my own home'... The golden time is right after discharge

Grandmother Lee Jeong-sook is opening the door and looking outside at her home in Jincheon-gun, Chungbuk on November 5. Photo by Kang Jin-hyung

Jincheon-gun is a rural area with a population of 80,000, consisting of 2 eup and 5 myeon. The only general hospital is Jungang Jeil Hospital located in Jincheon town. Elderly residents like Grandmother Lee visit Jungang Jeil Hospital when they experience falls or acute illnesses. Lee Jae-cheol, an officer of the Integrated Care Team at Jincheon County Office, said, "On average, about 10 elderly patients are discharged from this hospital each month. We started the Jincheon Integrated Care Service with the thought that we must not overlook these individuals."

For elderly people to continue living at home, the period immediately after discharge from the hospital is crucial. It is the 'golden time' at the crossroads between recovery and deterioration. If left alone during this time, their health can rapidly worsen and become fatal. Jincheon-gun proposed establishing an integrated care team at Jungang Jeil Hospital to monitor the health of elderly patients after discharge, providing an annual subsidy of 350 million won.

This led to the creation of the 'Care Station,' consisting of five nurses, one nutritionist, and one social worker. Their mission is twofold: first, to identify elderly patients in the hospital who need care after discharge through consultations; second, to visit the homes of these elderly patients to provide medical care. Medical care is not the only service?they also provide support with household chores, meals, and home repairs.

Medical care + nursing + household chores + meals: 'Integrated Care'

Grandmother Lee Jeong-sook is receiving a home visit medical examination from a care station nurse at her residence in Jincheon-gun, Chungbuk Province, on the afternoon of November 5 last year. Photo by Kang Jin-hyung

Ahn Eun-sook, the team leader of the Care Station, said, "Once a week, welfare officials, Care Station nurses, social workers, and visiting health care staff hold a video conference. In this meeting, we share cases of elderly patients and decide what services are needed and to what extent."

Grandmother Lee also became a recipient of integrated care immediately after discharge through this process. Although she is over ninety, her cognitive ability is good and she can walk, so she did not qualify for a long-term care grade. Therefore, she could not receive services from a care worker. Team leader Ahn said, "If the grandmother had not received integrated care services at home after discharge, her condition would have deteriorated enough to qualify for a long-term care grade."

As the grandmother finished her meal, nurse Lee In-hee from the Care Station peeked through the door. "Let me check your blood pressure first." The grandmother extended her wrinkled arm. The nurse said, "You were bedridden for the first two months after discharge, but now seeing you stand up, you might even visit the nearby senior center occasionally. You are taking your hypertension, arrhythmia, and osteoporosis medications regularly, so there seems to be no major issues."

The grandmother’s tense face finally relaxed. The nurse said, "Last summer was so hot that her youngest son installed an air conditioner. She was worried about the electricity bill, so she didn’t turn it on until summer was almost over. Maybe she’ll try using it next year. Even when it gets cold, just looking at it warms her heart. Her son bought her an air conditioner, so how could she leave her home?"