Preventing Hospital Re-Admissions for Home Health Patients

A Plan to Prevent Hospital Re-Admissions for Home Health Agencies

The estimated cost of unplanned hospital re-admissions was $17.4 billion in 2004, according to a study analyzing hospital re-admissions for Medicare beneficiaries using claims data from 2003 to 2004. With 19.6% of Medicare patients re-admitted to the hospital within 30 days and 34% within 90 days, it’s no wonder CMS began initiatives to reduce returns to the hospital. Since hospitals are now financially penalized for re-hospitalizations, the pressure on home health care agencies in the prevention effort has soared; and rightfully so. Home health is the next logical step after a hospitalization for a geriatric patient. It’s only a matter of time before CMS extends the financial implications of re-admissions to the home health and hospice sector. After all, many re-admissions occur on the home health agency’s watch. If the loom of inevitable payment reductions isn’t enough to push agencies to creating a re-hospitalization prevention plan, immediate drops in referrals may be. Many agencies that depend on hospitals for referrals are doing their part. In fact, if a home health care agency wants to market to a hospital discharge planner, they often go with a plan to reduce re-hospitalizations in hand.

Elements of a Hospital Re-Admission Reduction Plan

A re-hospitalization prevention plan sounds complicated, but it doesn't have to be. At TT Medical, we believe that business should be easy so we've simplified the prevention plan by breaking it down into 3 easy steps. 

Identify Vulnerable Patients

When creating a hospitalization prevention plan, the first step is to identify vulnerable patients. HHA's can decide to monitor all recently hospitalized patients or to narrow their focus to higher risk patients based on condition, age and other factors. The definition of "At Risk" patients for your agency should be based on the amount of work you can handle effectively. For example an agency with an average patient census of 1,000 may choose to create a narrow definition so they are able to handle the workflow. Smaller agencies may be able to afford to monitor all patients post hospitalization due to the lower number of hospitalizations they need to monitor. It's important to start with a smaller, manageable definition and progressively expand it if your agency can realistically handle the workload. A study that reviewed Medicare claim data from 2007 through 2009 concluded that geriatric patients returned to the hospital more often when their original admission was due to heart failure, myocardial infarction or pneumonia. Further, the average age of patients returning to the hospital for the 3 aforementioned conditions was 80.

Separate Your Plan Into Critical Time Points

The next step is to understand critical time points. 24.8% of patients admitted to the hospital due to heart failure returned within 30 days. 19.9% of patients admitted to the hospital due to myocardial infarction returned within 30 days. 18.3% of patients admitted to the hospital due to pneumonia returned within 30 days. 60% to 70% of all re-admissions occur within the first 15 days after discharge. Understanding the time tiers helps create an appropriate plan. For example, for the first 2 weeks the HHA staff should coordinate amongst themselves and the patient often, tapering down over time. We recommend starting with the following time periods:

  • While the patient is in the hospital

  • Days 1-3 after discharge from the hospital

  • Days 4-30 after discharge from the hospital

  • Days 31-60 after discharge from the hospital

  • Days 61-90 after discharge from the hospital

Establish Regular Communication

The largest factor in a successful hospitalization prevention program is effective communication within and outside of the home health organization. Designating someone to oversee the more aggressive coordination necessary is the best way to ensure all parties are participating properly. This person should:

  • Conduct regular case conferences with all involved field staff

  • Communicate often with other medical professionals involved in the patient's care

  • Keep in touch with the patient and any available caregivers

Sample Re-Hospitalization Prevention Plan

Agencies can start with this sample hospital re-admission prevention plan and then adjust according to their findings. The plan includes time-appropriate responses, without accounting for disease-specific actions. 

While the patient is in the hospital

Effective care coordination starts while the patient is still in the hospital. Agencies that keep in touch with patients, family members and hospital staff members about the patient's condition and discharge status will be more successful in the transition from the hospital to the home because hospital staff often give complicated instructions upon discharge at a time that patients and their caregivers may already be overwhelmed.

1-3 days after discharge from the hospital

The first 3 days after discharge are the most critical as the patient transitions back to the home setting. Often, patients have new medications, may be weak or even debilitated due to their recent spell of illness. Patients, family members and other caregivers need a lot of support in the first 3 days to learn about the new procedures, limitations and so on. Daily contact by nursing staff is recommended to help the patient and family get accustomed to their new routine.

4-30 days after discharge from the hospital

During this time period, agency staff needs to focus on medication compliance and establishing a routine amongst the patient's caregivers. If appropriate, consider sending a home health aide to help the patient and family/caregivers while they are adjusting to the recovery phase. Home health office staff should also try to maintain weekly communication with the patient, family members and all involved disciplines for the first 30 days, updating all involved physicians weekly. 

31-60 days after discharge from the hospital

Once the patient seems like they are in stable condition, case conferences and patient/caregiver communication can be reduced to twice a month, updating all participating physicians after each case conference. 

61-90 days after discharge from the hospital

Don't assume that just because the initial 60 day period has passed that your patient is cleared. According to "Gaining Ground: Care Management Programs to Reduce Hospital Readmissions and Readmissions Among Chronically Ill and Vulnerable Patients" about 33% of all hospital re-admissions happen within 90 days. It's important to continue to monitor your patient's progress and make sure they are aware of the disease-specific symptoms they need to look out for. Case conferences and patient communication can decrease now to once monthly.

Marketing to Hospitals with a Good Plan

Hospitals are financially penalized for patients who return within 30 days after discharge. Eliminating hospital re-admissions is unlikely, but reducing the number of patients that go back is realistic. When marketing to hospitals, show them that your agency is successful in keeping patients from returning to the hospital within 30 days, once they are discharged. Show your plan and ask for feedback. A collaborative approach can help you both with you marketing efforts and the further development of your plan.

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