Collaboration Brings Home Health to Forefront of Hospital Discharge Process

Mercy, a member of the largest health system in Ohio, has entered into a Care Collaboration Agreement with Senior Independence (SI), a Medicare-certified provider of home health and hospice services in Ohio.

The agreement seeks to increase the overall well-being of patients through education and management of chronic diseases; reduce avoidable hospitalizations, hospital readmissions and emergency department visits; and decrease the overall costs of medical care.

Mercy and SI, whose parent organization is Ohio Presbyterian Retirement Services, will work together to improve quality and patient service, and facilitate enhanced access to appropriate health care services across the continuum of care.

At the heart of the collaboration is the importance of home health care in the hospital discharge process.

“Home health has really risen to a priority level for the first time in a long time in terms of being able to care for patients,” Wendy Price Kiser, executive director of SI, Greater Toledo, tells HHCN. “Our goal is to provide the best, highest quality care in this new health care arena.”

SI’s hospital readmission rate is around 3.2%, a level Price Kiser attributes to the company’s care transition program, called the Home to Stay Program, which helps recently hospitalized patients better manage chronic disease.

When a patient is well enough for discharge, a Home to Stay team determines whether the patient requires skilled home health care. If so, a home health nurse visits the home within 24 hours and SI provides ongoing care. If the patient does not require skilled home health care, a Home to Stay nurse visits the person at his or her home within the next 72 hours and again seven to 10 days after discharge.

“Before Home to Stay, many people were left on their own,” said SI President Rich Boyson, in a statement. “Now, they’re getting help with medications, being provided an evaluation of their home setting, learning what questions to ask at doctor appointments, and creating lifesaving personal health records.”

Services provided by SI include a medication review, monitoring of vital signs, discussion about a personal emergency plan and confirmation of follow-up appointments, among other services. The in-home visits are followed by a series of phone calls by a nurse or social worker over the next 21 days.

“Immediate and close follow-up after hospitalization has been shown to improve clinical outcomes, improve patient and family experience, and reduce the need for readmission,” said Ken Bertka, Mercy’s chief medical officer, in a statement. “We are delighted to partner with Senior Independence to improve care and make it easier for our patients.”

Education is also a big part of SI’s Home to Stay Program, Price Kiser says.

“We work very hard to educate clients and their families on the signs and symptoms of when to call us, so instead of abruptly going to the emergency room or going to the hospital, we try to put mechanisms in place where they can identify issues first,” then decide whether a trip to the ER is necessary, she says.

In addition, Mercy and its parent company Mercy Health operate Mercy Health Select, an integrated health network of hospitals and physicians across Ohio, which participates in the Medicare Shared Services Program as an accountable care organization (ACO) to serve the needs of traditional Medicare patients.

The Shared Savings Program allows health care providers to coordinate services along the continuum of care to improve health, improve care and lower cost.

The affiliation with MHS means that Mercy patients will now have enhanced access to coordinated care after discharge, at home or in a skilled nursing facility. The ultimate goal is to reduce hospital readmissions for these patients through better coordination and communication.

“As a core member of the post-acute network, I think that we have to work closely with the hospitals as well as the skilled nursing facilities and extended care facilities,” Price Kiser says. “Now we’re being asked to manage care throughout the continuum, and we just can’t do it in isolation.”

Written by Emily Study