In the current Home Health environment, efficiency, quality, and cost-effectiveness have become a primary focus. Due to an increase in utilization, and attendant cost increases, home health care has become a target for cost reduction by Medicare. As the government zeroes in on cutting unnecessary expenditures, agencies are being monitored for several quality indicators, one of which is how well we perform in keeping patients out of the hospital. The pay-for-performance program will reimburse home health agencies based on how successful they are in preventing re-hospitalizations.

According to a recent study published in the New England Journal of Medicine, “Medicare expenditures for potentially preventable re-hospitalizations may be as high as $12 billion a year. Almost 20% of 11,855,702 Medicare beneficiaries studied who had been discharged from a hospital were re-hospitalized within 30 days, and 34% were re-hospitalized within 90 days.” [1]

Medicare is the largest insurance payer for both Home Health Care and then subsequent hospital stays in a large number of the senior population; therefore much attention is being paid to these two entities.

Prevention of re-hospitalizations begins at the moment of referral. By executing the following measures, agencies can significantly decrease a patient’s risk of unplanned and unnecessary re-hospitalization:

1. Ask the referral source for recent documents that describe the patient’s health status. Examples include History and Physical, Reconciled Medication Profile, list of diagnoses, and any procedure/surgical notes.
2. Perform an accurate and thorough assessment of the patient’s health history, support system available, knowledge of disease processes and medications, and economic status on admission. If a patient cannot understand why he or she is ill, if they have inadequate resources needed to get to and from the physician or to purchase prescribed medications, for example, other efforts to meet the patient’s goals will be slow and tedious.
3. Implement a patient specific plan of care. Start the nurse’s visit frequency high, and decrease with time. This allows intensive teaching and assessment when the patient is still in acute phase of illness.
4. Be sure you look at the patient’s medication bottles at admission and often thereafter. You can glean much information about compliance and patient understanding by looking at the fill dates of medications and checking the number of tablets or capsules left in a bottle.
5. Provide adequate coordination of care between clinical staff, therapy staff, family members, agency managers, and physicians. This is an area often cited deficient by surveyors, and often for good reason. By keeping other staff and family members “in the know” about a patient’s status, we can often prevent complications as others assist in checking on areas of concern.
6. Implement a “know when to call your nurse” symptom list. Instruct the patient on signs and symptoms that require follow up by a professional, and when they should call and report these problems. Early intervention prevents ER visits, and PRN visits can often interrupt progression of disease process.
7. Be sure the patient follows up with their physician as soon as possible, ideally within a week, after being discharged from a hospital. Be sure they make an appointment and have a way to get to the clinic for follow up.
8. In the event a patient goes to the hospital, be sure to communicate with the hospital staff. Call the ER and give a status report. Send the hospital copies of the current Plan of Care/485, medication profile, and transfer summary. Be sure the transfer summary provides correct and adequate information on the patient’s health status.
9. Designate someone in your office who will call daily and check on the hospitalized patient’s status. Facilitate communication with the discharge planner and establish rapport with them. This will often improve the chance of your getting information from the facility that will help manage the patient’s care upon their return home.
10. Make a visit to reassess the patient as soon as possible following a hospital discharge. Reconcile the patient’s medications on discharge against the medication profile prior to hospital stay. Notify the physician if any undocumented discrepancies are found. Involve a family member in this post-hospital visit whenever possible. Provide intensive teaching on the primary disease process that caused the hospitalization as well as any new and/or changed medications. Increase the frequency of visits for a couple of weeks to keep a close watch on the patient status.

By implementing these changes, you can decrease your patient’s risk of unnecessary re-hospitalizations greatly. Not only will this benefit your patients, it will benefit your agency in the near future as Medicare recognizes your high quality services and rewards your agency accordingly.

Reference: [1] New England Journal of Medicine. “Re-Hospitalization among Patients in the Medicare Fee-For-Service Program”. Stephen F. Jenks, MD, MPH et al. 04/02/2009.