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Optimizing Home Health Outcomes With Better Care Transitions

Home health agencies are critical partners amid care transitions from hospitals to post-acute settings, especially as higher-acuity patients opt for care in their homes. 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 home health care transition, and healthcare costs mount.

Taking steps to reduce hospital 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

The Centers for Medicare and Medicaid Services (CMS) aimed to empower patients during these transitions by issuing 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.

The CMS rule specifies that:

  • 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.

Incentives for Better Care Transitions

The quality of care provided to a patient leaving the hospital for the home hinges on an effective care transition. That requires a partnership between hospital and home health staff as well with the patient and any family and caregivers involved.

When your home health agency has a consistent record of quality transitions, you position your organization to:

  • Serve as a strong referral option for hospitals
  • Provide a good choice for patients and families, based on your ratings and reputation
  • Optimize CMS reimbursement percentages, which can be affected by quality ratings

The collaboration between the referring hospital and the home health agency begins before the patient leaves the hospital. Then the initial home visit by a nurse or physical therapist focuses on timely patient assessment, patient and family education, and follow-up coordination of healthcare services.

Further, organic business growth also depends on the quality of care you provide. CMS quality ratings have  repercussions on your reputation, and patients and their families look at those factors to determine if your agency is the best choice for them.

The measures used for the CMS Home Health Quality Reporting Program (QRP) include potentially avoidable events for home health agencies. The QRP outcomes tracked and reported include hospital readmissions within 30 days of discharge into home health.

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.

Other risk factors in the post-acute arena can directly affect readmission. A 2020 study by the Centers for Disease Control and Prevention found that COVID-19 survivors had a 9% readmission rate within two months of discharge. Other readmission factors include social determinants of health.

Further, 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 Home Health Care 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.

Editor’s Note: Updated in September 2021 to reflect changes due to COVID-19.


Identifying Root Causes of Variation in Clinical Competency and Organizational Quality

Home health and other post-acute care organizations must demonstrate quality to maintain and enhance their financial strength. Assessing areas of risk can help leaders create plans to remediate weaker elements, enhance clinical competency, and strengthen quality to garner referrals.


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