Hospital Readmission Reduction: Four Tips for Home Health Agencies

Hospital readmission reduction is a hot topic in healthcare these days. Studies show that nearly 20% of Medicare recipients discharged from a hospital were readmitted within 30 days, with 34% readmitted within 90 days. MedPAC has estimated that 12% of readmissions are avoidable, and preventing even a small portion of these readmissions could save Medicare millions of dollars. Additionally, in 2009, CMS began publicly reporting hospital readmission rates through their Hospital Compare website. According to CMS, publicly reporting these measures increases transparency into hospital care, provides valuable information consumers can use to choose care, and helps hospitals with quality improvement efforts.

Since the Hospital Readmissions Reduction Program (HRRP) was established as part of the Affordable Care Act, CMS reduced Medicare payments to hospitals with excessive readmissions within 30 days of discharge for certain conditions by $2.28 billion dollars between 2010 and 2016.

As a result, hospitals are directing their attention to home health agencies to help reduce readmissions. It is imperative that agencies demonstrate the ability to reduce hospital readmissions to not only earn referrals, but to produce better clinical outcomes, which is important when patients are looking at rankings on Home Health Compare and when agencies are marketing to the community.

Four Tips for Hospital Readmission Reduction

Interdisciplinary Approach to Care

Home health agencies can take a cue from hospices when it comes to implementing a team approach to patient care. Holistic care is difficult when provided by a single professional or within professional silos. Interdisciplinary collaboration breaks down information silos, fostering open communication and care coordination for better patient outcomes and satisfaction.

A recent Home Health Care News article discussed how one hospital-based home health provider has developed an interdisciplinary team (IDT) that includes a home care nurse, clinical care manager, physician, pharmacist, palliative care representative, and a social worker. This team approach has resulted in better care coordination and better communication across professionals.

Additionally, as part of the revised Home Health Conditions of Participation, home health agencies are expected to take an IDT approach to care, as noted in “Standard: Responsibilities of skilled professionals.”

Enhanced Patient Education

According to a study funded by the Agency for Healthcare Research and Quality (AHRQ), patients who receive education about their post-acute care are 30% less likely to be readmitted or visit the emergency room than patients who do not.

While not all hospital readmissions are avoidable, enhanced education and communication with patients and their family members can significantly reduce the number. Ensuring that patients have a complete understanding of their post-hospitalization self-care instructions is vital. Knowing how and when to take medications, when to visit the emergency room, dietary restrictions, signs and symptoms of decline in condition, and when to contact the home health agency or physician equips patients with the knowledge needed to be proactively involved in their care, minimizing their risk of readmission to the hospital.

High-Risk Patient Identification

Knowing which patients are at risk for readmissions is vital. These patients need to be identified and closely monitored. Often, hospital readmissions are not related to the “official” diagnoses, but to underlying comorbidities present during the episode of care. Special attention must be given to the management of comorbidities in order to fend off potentially avoidable hospital readmissions. Staff should be aware of a patient’s “high risk” status so they can pay special attention to signs of worsening symptoms.

According to a study by the British Medical Journal, “infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder were the most frequent primary diagnoses of potentially avoidable readmissions. Almost all of the top five diagnoses of potentially avoidable readmissions for each comorbidity were possible direct or indirect complications of that comorbidity.”

High-risk patients need to be monitored regularly between visits through phone calls or remote telemonitoring systems. This allows home health agencies to immediately address worsening symptoms before they result in a readmission.

Use of Technology

Technology can play an important role in hospital readmission reduction. Home health software systems with comprehensive clinical documentation enable home health agencies to record and share vital information such as readmission risk status. All members of the team can view every detail of a patient’s care plan so that everyone is on the same page, working towards the same goals. This reduces the risk of errors and increases collaboration among the care team, ultimately resulting in better outcomes and patient satisfaction.

Focusing on hospital readmission reduction should be a top priority for all home health agencies not only because it can lead to increased referrals, but because it is an important element of providing complete, quality care.

HEALTHCAREfirst helps home health agencies reduce hospital readmissions with comprehensive clinical decision support tools that facilitate a proactive, interdisciplinary approach to care. All members of the care team have anytime, anywhere access to vital patient information, enabling them to clearly communicate and educate patients while identifying high-risk patients for closer monitoring.

The HEALTHCAREfirst Difference

See why thousands of home health agencies across the country trust firstHOMECARE with CAREpliance technology to ensure they provide the highest quality, patient-centered care without sacrificing efficiency or patient/caregiver satisfaction.

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