Preventing Rehospitalizations in Home Health

Preventing Rehospitalizations in Home Health

A home health agency’s success in helping patients stay safely in their home through high quality care is important for patients, physicians, SNFs, ALFs, ILFs and CMS. Preventing rehospitalization is a home health industry challenge with the annual cost of rehospitalization within 30 days of discharge estimated at $41.3 billion. As one of the claims-based measures associated with HHVBP, acute care rehospitalization counts for approximately 26.25% of the total 35% score. What are the top reasons for rehospitalization in home health? Let’s take a look.

• Falls
• Infections
• Wound Complications
• Chronic Conditions including CHF, COPD and Diabetes
• Medication Errors
• Lack of timely follow-up

Home health agencies must make reducing rehospitalization a priority to prevent negative impacts to patient outcomes, star ratings, and operational performance metrics. Providers are searching for agencies who can successfully manage patients at home and become a valued partner in conquering the burdens of rehospitalization together.

Tips on Managing the Top Readmission Challenges in Home Health

Timely Admissions

Ensuring timely admission is key to reducing the risk of rehospitalization. Ensure that your agency has an effective intake process and scheduling system to promptly manage new admissions. While CMS requires that patients are admitted within 48 hours of discharge, the most successful agencies strive for the same day admission or admission within 24 hours. Limiting the time that patients are without home health care post discharge is crucial to reducing unnecessary readmissions to the hospital.

Medication Reconciliation

Agencies must train and educate all clinicians, both nursing and therapy, on the importance of medication reconciliation upon admission and during each follow-up visit. Many patients who are returning to their home have encountered multiple medication changes since last leaving home. Thorough medication reconciliation ensures that the patient is taking the correct medications at correct dosages to reduce the risk of exacerbations of disease processes or other setbacks in their recovery.

Fall Prevention Programs

Fall prevention is an important area of focus. Falls within the elderly population can be a detrimental setback for those striving to remain in their own home. Fall risk assessments and patient centered intervention should be a priority, especially upon admission with ongoing reassessment and education throughout home care treatment. Fall prevention programs focused on patient safety should be implemented routinely. Fall prevention is also a great way for agencies to partner with the community ALFs to ensure that joint patients stay safely in place and maintain independence.

Infection Control

Infections such as wound infections and UTIs present the risk for rehospitalization. Clinicians must be trained to quickly identify and address potential infections. Wound assessments should be routinely performed and abnormalities or suspected deterioration in wounds communicated immediately to the supervisor and physician. Collaboration with local or mobile wound care centers can add extra support in preventing wound infections. Addressing any signs or symptoms of a UTI with urgency is also critical in rehospitalization prevention, as UTIs can result in rapid decline of elderly patients.

Disease Process Management

Exacerbation of both chronic and new onset conditions such as CHF, COPD and diabetes leave home health patients at risk for rehospitalization. Again, ensuring that all clinicians are trained to monitor and assess for signs and symptoms of exacerbation is crucial. Interventions such as patient education and daily weights are instrumental in preventing or catching the signs early. Customizing assessments to consider condition specific risks—for example, checking to be sure a CHF patient has a scale in the home is helpful. Development of disease process programs with an emphasis on reduction of rehospitalization ensures consistency in disease process management.

Reducing Staffing Turnover

Turnover in home health can impact rehospitalization in many ways. Staff shortages can lead to delayed patient care that leaves patient vulnerable. Constant turnover and limited clinician experience can lead to gaps in patient assessments, inconsistency in patient care and reduced buy-in for staff to make a positive impact. A consistent, knowledgeable team is the best defense against rehospitalizations.

Contact Proactive Home Health Consulting for assistance in reducing rehospitalization.

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