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Strategies to Reduce Hospital Readmissions in Home Health


Patient rehospitalizations have a significant impact on home health organizations and can be prevented in many situations.

Every year, the Centers for Medicare and Medicaid Services (CMS) penalizes acute care hospitals that have too many Medicare patients readmitted within 30 days of their original discharge. This can negatively impact referrals for organizations with high readmission patterns.

Rehospitalizations Also Impact Quality

High numbers of rehospitalizations also impact an organization’s outcome measures, which are publicly reported on Care Compare. This can further reduce referrals from sources seeking better outcomes and lower risk of patients returning to their care within 30 days of discharge.

How to Reduce Hospital Readmissions

Reducing readmissions starts with appropriate hospital discharge planning.

Paste paragraph text. All training and education should be completed prior to discharge, with the caregiver present. This has been challenging recently due to facility policies during the current COVID-19 emergency; however, it is essential for post-discharge success.

Examples of this teaching include therapy training for stair transfers if the patient has stairs in their home, ostomy instruction for a patient with a new ostomy or insulin training for a patient recently diagnosed with diabetes.

Thorough Pre-Discharge Planning

Other pre-discharge planning considerations include ordering durable medical equipment (DME) and verifying that it will be in the home when the patient is discharged. This is particularly important for patients going home on oxygen or suction.

Organizations should ensure that the patient has enough essential wound care or ostomy supplies to get them through the first few days. This will give the organization time to order and have supplies delivered to the patient’s home.

What to Consider When Admitting the Patient

If possible, the organization should consider a day of discharge or next day admission, with the patient’s support person present. This initial visit should focus on the patient’s functional ability, where they can get help if needed and medication teaching.

If possible, the organization should consider a day of discharge or next day admission, with the patient’s support person present. This initial visit should focus on the patient’s functional ability, where they can get help if needed and medication teaching.

Other important considerations during the first visit:

  • Assessment of support systems available in the home
  • The ability and willingness of a caregiver to assist with personal and hygiene needs
  • Adequate food availability in the home
  • The patient’s ability to manage medications if they are drowsy or weak in the first few days

Other Tips to Reduce Readmissions

Instruct patients to call the organization first and speak with the nurse on call versus immediately returning to the hospital, except in an emergency.

Friday afternoon phone calls from the case manager or office team are also a good way of “tucking in” the patient for the weekend, ensuring they have all their needs addressed before their regular providers are inaccessible over the weekend.

Organizations have also found it helpful to schedule therapy soon after admission if the patient is experiencing weakness, exhaustion or pain. This will help avoid a rehospitalization, as the caregiver being unable to cope with the patient’s physical needs and pain is a frequent reason cited for returning to the hospital.

Finally, verifying that the patient has an appointment with their primary care physician within the first week after discharge ensures good continuity of care and facilitates any follow-up required.

Using these tips, home health organizations will reduce hospital readmissions, improve their quality of care and make themselves more desirable to referral sources.

Axxess Home Health, a cloud-based home health software, includes a built-in PDGM dashboard that identifies patients’ hospitalization risk during the comprehensive assessment and at recertification.

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