Optimizing Home Health Outcomes With Better Care Transitions

Home health is often overlooked as being a critical partner amid transitions from hospitals to post-acute care settings. The movement of patients from one setting or practitioner to another carries high potential for serious complications and breakdowns in communication. Patients suffer when there is a poor care transition, and healthcare costs mount.

Moving patients from the post-acute sector back into the acute sector— known as “hospital readmission”—is something that no one wants to see happen. The costs can be physical, emotional, and financial.

Taking steps to reduce readmissions is vital to ensuring consistent care, optimizing patients’ health and well-being, and maintaining the financial strength of healthcare organizations. Many home health agencies have taken action to create their own care transition models, policies, and procedures to improve patient outcomes, but there is still work to be done.

Healthcare providers, caregivers, community social services, and patients themselves can contribute to the success of readmission reduction efforts.

Patient Agency and Informed Decisions

A recent directive from the Centers for Medicare and Medicaid Services (CMS) is designed to empower patients during these transitions. CMS issued a Final Rule in September 2019 that changed discharge planning requirements for all home health agencies and providers.

The goal is to encourage patients to take a more active role in their care transitions from the hospital into other settings, support patient choice for post-acute care, and avoid having hospital discharge planners steer patients toward a preferred provider. The rule emphasizes that agencies must continue to abide by the IMPACT Act and home health Conditions of Participation, as noted in Home Health Care News.

Under this new rule:

  • Patients and their families must have access to information that can help them make decisions about their post-acute care.
  • Home health agencies must provide data to patients and their caregivers regarding quality measures and resource use measures, both of which must address the patient’s preferences for treatment and their goals for care.
  • The discharge needs of patients and their discharge plan must be evaluated in a timely manner, included in the clinical record, and discussed with the patient or their representative.
  • All relevant information about the patient must be part of the discharge plan to avoid discharge and care delays.

Financial Repercussions of Readmissions

To reduce the financial impact of rebound hospitalizations, the CMS Hospital Readmissions Reduction Program (HRRP), tracks readmission rates and reduces hospital payments if HRRP calculations show the hospital has an excessive rate. Those penalties were reported to be $564 million for 2,500 hospitals in fiscal year 2018, according to the healthcare industry research group Advisory Board.

CMS also tracks potentially avoidable events for home health agencies under the Home Health Quality Reporting Program (QRP). The QRP outcomes tracked and reported include hospital readmissions within 30 days of discharge into home health. Quality measures naturally can have a negative impact on the number of referrals home health agencies receive.

The Agency for Healthcare Research and Quality (AHRQ) has noted that hospital readmissions are among the most expensive episodes to treat, costing approximately $41.3 billion in 2011 for patients readmitted within 30 days of discharge.

More recently, AHRQ has reported that the hospital readmission rate for Medicare patients 65 and older decreased from 17.4 percent in 2010 to 16.0 percent in 2016, with the number of readmissions for that Medicare age group still at 1.8 million patients in 2016.

Understanding the Risk Factors

Hospitals have traditionally been the focal point when targeting readmissions, with emphasis on the quality of care and discharge planning. One of the most commonly encountered gaps in continuity of care is between the hospital and home health, Healthcare IT News notes.

Problems can stem from communication lapses between the transferring provider and the receiving provider. Approximately 33% of home health agencies do not receive documentation from the hospital, and only 12% to 34% of the hospital discharge summaries actually get to the home health care team, according to Healthcare IT News.

Today, healthcare professionals acknowledge that there are other risk factors in the post-acute arena that can directly affect readmission, many of which are outside the healthcare organization’s control. They include social factors such as socioeconomic status, mobility, family support, and race, as Healthcare Business & Technology reports.

More specifically, a study published in the Journal of General Internal Medicine found the following risk factors:

  • Patients with pneumonia who had difficulty with daily tasks such as cooking or getting dressed before their hospitalization were highly likely to be readmitted to the hospital within 30 days.
  • Patients with heart failure were likely to be readmitted if they:
    • Were poor
    • Were African-American
    • Had no adult children
  • Patients hospitalized for a heart attack who lived in long term care before their hospitalization were highly likely to be readmitted to the hospital.

Tools for Better Transitions

The Alliance for Home Health Quality and Innovation (AHHQI) has published its model for improving the transition from hospital to home health, including tools to support the changeover in care settings. AHHQI observes that there has not yet been a truly comprehensive effort to identify the actual steps, processes, or tools that should be standardized in home health for managing the care transition between the hospital and the home health setting.

The AHHQI identified five core values for the care transition model:

  • Focus on the patient
  • Medication management
  • Care coordination and communication
  • Timely follow-up by the primary care physician and the home health care team
  • Coaching and education for the patient

This approach is designed to foster high patient satisfaction and reduce 30-day avoidable readmissions to the hospital.

The AHHQI publication provides additional information, including:

  • Transitional care checklists
  • Key elements and core components lists for tools
  • Guidance for providing transitional care
  • Evidence-based care transition tools

Returning to the idea of patient agency in improving the move to home health services, a patient-facing discharge preparation checklist is available from The Care Transitions Program.

A list of resources provided by other organizations and networks for state and community providers is available via the Medicaid.gov website.

In terms of next steps, assessing areas where your organization may need assistance in enhancing competency and communication and providing targeted training are important elements to improve care transitions as well.

Ultimately, you will have to decide which models and tools your agency will employ in pursuing effective, efficient care transitions. A coordinated, strategic approach can strengthen the bottom line for your home health agency and the outcomes for your patients.

Jennifer Burks

Lead SME Writer, Relias

Jennifer W. Burks, M.S.N., R.N., has over 25 years of clinical and teaching experience, and her areas of expertise are critical care and home health. She earned her Bachelor of Science in Nursing from The University of Virginia in 1993 and her Master of Science in Nursing from The University of North Carolina, Greensboro, in 1996. Her professional practice in education is guided by a philosophy borrowed from Florence Nightingale’s Notes on Nursing, “I do not pretend to teach her how, I ask her to teach herself, and for this purpose, I venture to give her some hints.”

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