There are certain times, as a nurse, when something you read or hear resonates so deeply, is so meaningful, is such a light bulb moment, that you never forget it. 

For me, on my clinical journey, it was one paragraph in a paper published by Harlan M. Krumholz, MD. 

“During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and other discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity.  

Dr Krumholz, aptly named this, “Post Hospital Syndrome.” 1

Why then, do we continue to treat only the acute condition when the whole patient has been impacted by a hospitalization? Dr Krumholz goes on to show that readmissions are often not for the same reason as the original hospital admission. A patient originally admitted for a heart failure exacerbation might be readmitted for a fall or a urinary tract Infection. Unless we truly use a whole-patient approach to reduce hospital admissions and readmissions, we may never get ahead.

Post Acute Care & Sleep 

Let’s dive a little deeper into sleep, one of the risks associated with post-hospitalization recovery. Poor sleep is not only associated with an increased risk of cognitive decline, but also depression, falls, chronic disease, and obesity. Post-hospitalization or post-acute care must include strategies to first identify and then address sleep-related issues that may impact a patient’s recovery.  

This is where post-acute care technology, like telehealth and remote patient monitoring (RPM), can play a vital role. Delivering and installing telehealth and RPM devices as soon as possible after hospital discharge is critical to patient success. It's important to monitor the recommended biometrics as soon as day 2 post-hospitalization. Unless otherwise indicated, patients are quite fatigued and overwhelmed when first coming home. So, a day of rest first is important. 

During a home health admission, for example, ensure the essentials of the OASIS (Outcome and Assessment Information Set), comprehensive assessment, and medication reconciliation are completed. Limit education to only the most critical information, such as who to call if the patient develops any signs or symptoms of an adverse event requiring immediate attention. That alone can be a very time-consuming and tiring process for the patient and the nurse. 

There are several OASIS questions related to sleep: sleep interrupted by pain; exhaustion, which if present, contributes to hospitalization risk, and in the Mood section, questions are asked about feeling tired, having no energy, trouble falling, staying asleep, or sleeping too much. Together, these assessments can identify a sleep problem, but how often is it included in the care plan with actions to mitigate? While the OASIS touches on sleep, there is no overall indicator that sleep is an issue.  

The Sleep Assessment Survey

For patients not admitted to home health following a hospitalization, a sleep assessment might not be included at all.  

This is where Telehealth and RPM for post-acute care can be extremely helpful in tracking and trending sleep issues. Sleep-specific survey questions delivered to the patient or their caregiver via telehealth can determine if the patient is getting adequate and restful sleep. 

The Sleep Assessment Survey developed by the HRS (Health Recovery Solutions) Clinical Team is based on the recommendations from the National Sleep Foundation and includes 4 metrics to determine sleep quality: 

  • “Sleep latency: This is a measurement of how long it takes you to fall asleep. Drifting off within 30 minutes or less after the time you go to bed suggests that the quality of your sleep is good. 
  • Sleep waking: This measures how often you wake up during the night. Frequent wakefulness at night can disrupt your sleep cycle and reduce your sleep quality. Waking up once or not at all suggests that your sleep quality is good. 
  • Wakefulness: This measurement refers to how many minutes you spend awake during the night after you first go to sleep. People with good sleep quality have 20 minutes or less of wakefulness during the night. 
  • Sleep efficiency: The amount of time you spend actually sleeping while in bed is known as sleep efficiency. This measurement should ideally be 85 percent or more for optimal health benefits.” 

Telehealth & Remote Patient Monitoring in Post Acute Care

Adding the Sleep Assessment Survey to the post-acute telehealth and remote patient monitoring (RPM) program can identify potential rehospitalization and other risks. Combined with the collection of biometric data and other symptom surveys, the monitoring clinician can make a more comprehensive assessment and intervene appropriately. 

The Sleep Assessment Survey is designed to identify sleep issues so that they can be properly addressed by lifestyle changes or medications that can not only reduce risk but improve the quality of life for our patients. 

Sleep—good, restful sleep—is essential for overall health and well-being. It is an especially critical component of recovery following a hospitalization. 



1. Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013 Jan 10;368(2):100-2. doi: 10.1056/NEJMp1212324. PMID: 23301730; PMCID: PMC3688067.