3 Simple Ways Home Health Can Reduce Hospital Readmissions

It’s no secret that many home health agencies are turning to the latest technology and software to improve patient outcomes and reduce hospital readmissions, but other strategies require getting back to the basics of connecting with patients.

“Hospital readmissions are a driving factor in escalated health care costs,” said Rosann Prosser, director of clinical operations with Presence Health, at the Illinois HomeCare & Hospice Council 2015 Annual Conference & Exposition on Wednesday.

The drive to reduce costs across the U.S. health care system has put pressure on providers of all types — including home health — to bring down rehospitalizations. But it’s not just a dollars-and-cents issue, and Prosser and her fellow panelists emphasized that providers need to recognize the challenges patients face after hospital discharge.


“The most vulnerable time emotionally and physically for patients is between the time of hospital discharge and their return home,” Prosser said.

With this in mind, leading home health agencies are ramping up education and communication efforts to put patients in the driver’s seat of their health care while also identifying those who are at a high risk for hospital readmission. And these efforts are paying off as seen through increased patient satisfaction, reflected in better survey results.

1. Patient education


Initiatives that focus on patient education are key to overall success, said Sheila Guither, manager of clinical practice at OSF Home Care Services.

“You want to make sure you’re giving the patient the tools and resources they need to manage their own care and move on in their life — those tools that keep them out of the hospital, which is our goal,” she said.

Clinicians need to help patients identify a goal that is meaningful to them, and help them work toward it. For example, a clinician might have the goal of getting a patient’s heart stable, but the patient’s goal might be to go back to work, or play with the grandkids.

“Make goals meaningful,” she said.

Agencies can also benefit from implementing a health literacy evaluation.

“You can’t assume a patient who is an engineer knows anything about health care, nor can you assume a patient who dropped out of eighth grade knows nothing about health care — understanding health literacy helps tailor patient education to the needs of patient and caregiver,” she said.

A health literacy assessment also helps identify who the “key learner” will be, she said, noting that the key learner might be the adult child or spouse of the patient depending on the patient’s health care needs.

Avoiding medical jargon is crucial when working with patients, as is offering patient education materials from the same sources to promote consistency company-wide.

2. Medication management

An important component of patient education is medication management, and assessing what barriers the patient might face with their medication schedule early on, said Maria Ferraro, clinical manager at Centegra Home Health.

“One of the factors that influence [hospital] readmission is medication,” she said. “Whether it’s the patients inability to afford medication, or not understanding how to take it.”

Medication teaching is incorporated into all Centegra Home Health caregivers’ first admissions visit with patents, she said, noting that those who are identified as “high risk” will receive a second visit dedicated to medication teaching.

A questionnaire used during the admission visit asks questions including, “Do you understand the side effects of your medication? Are you able to open the pill bottles?” and more, she said.

Self-reporting tools give clinicians the opportunity to focus in on what is a challenge for patients, rather than what the clinician perceives is a challenge, which promotes overall better care, she said.

3. Tackling ’survey fatigue’

Convincing patients to fill out the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey is a common challenge for agencies, industry members said. The HHCAHPS Survey is designed to measure the experiences of people receiving home health care from Medicare-certified home health agencies, and is submitted quarterly.

“Patients have survey fatigue, they’re getting a survey from hospitals, outpatient care [and from other sources],” Ferraro said.

But if a clinician can communicate the survey’s value to patients in context to their own health, more clients are likely to participate, she said.

For example, a caregiver can say, “‘You are going to get a survey, and remember it’s specific to home health,” she said. “‘This is your chance to help me understand how well I’m doing because I really want to do the best I can.’”

To encourage high levels of patient satisfaction and better HHCAHPS Survey results, home care agencies should perform post-admission phone calls within seven days after the start of care. This helps identify any issues early on, Prosser said.

Keeping team members in the loop is also key, Prosser said, noting that team meetings should include reviews of patient satisfaction questions and opportunities to role-play different interactions and scenarios.

The more patients participate in the HHCAHPS Survey, the more consistent the feedback, which helps to identify areas that need improvement, Ferraro said.

“Patients are very aware,” she said. “You want them to say you gave them the best care that you could.”

Written by Cassandra Dowell

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