Lisa Frain
Jul 25 2023
Reading Time: 3 minutes
In home health and hospice, significant effort from everyone along the care journey goes into delivering patient-centric care. A lack of coordination across care settings can result in more (often avoidable) readmissions. When these readmissions are reduced, quality of care and the patient and family experience can be improved.
In this blog, we explore how organizations can work toward reducing avoidable rehospitalizations.
Improving care transitions to help avoid rehospitalizations
With hospitalizations accounting for nearly one third of the total $2 trillion spent on healthcare in the U.S., finding innovative ways to prevent avoidable readmissions can help improve care, reduce waste, and increase efficiency in home health and hospice.
Up to 76% of rehospitalizations occurring within 30 days of discharge in the Medicare population are potentially avoidable.(Analysis conducted by the Medicare Payment Advisory Committee — MedPAC)
Up to one third of patients with multiple chronic conditions return to the hospital due to complications that could have been prevented, including:
- Poor hospital discharge processes
- Patients’ inability to manage self-care
- Lack of quality care in the next community setting
- Scarcity of care resources for high-risk patients
There are three key ways to help ensure transitions to the home are done successfully:
- Get face to face with patients and caregivers before they’re discharged from the hospital to discuss the transition home and schedule a follow-up appointment.
- Assess the patient at the first post-discharge home visit by evaluating clinical status, reconciling medications and providing education on the plan of care using the teach-back method.
- Engage the entire care team through a patient-centric EHR, real-time communication and streamlined workflows for efficient referral processes.
Understanding patient risk for rehospitalization
High-risk patients have been admitted two or more times in the past year and their caregiver is unable to teach back or has a low degree of confidence to continue care in the home.
Moderate-risk patients have been admitted once in the past year and their caregiver has a moderate degree of confidence to continue care in the home.
Low-risk patients have had no other admission in the past year and their caregiver has a high degree of confidence to continue care in the home.
Most patients who are readmitted are readmitted within the first seven days post-discharge, so scheduling the first two visits within the first 48 hours can help set these patients up for success.
Intervention at the point of transition
As a strategy to reduce avoidable rehospitalizations, home health and hospice staff should be proactive about intervening when necessary during the transition of care. Patient-centric support like real-time communication, documentation at the point of care and on-demand education can streamline coordinated care and help reduce avoidable readmissions.
Talk with a CitusHealth expert to learn all the ways our all-in-one platform can help with avoidable rehospitalizations.
