Beyond Readmissions: Inside One Health Network’s Home Care Initiative

Reducing medical expenditures and lowering hospital readmission rates are only part of the equation when it comes to one health network’s all-encompassing home care initiative.

More than anything, Pittsburgh, Pennsylvania-based Allegheny Health Network (AHN) is focused on maintaining control over the quality of care and services delivered once patients leave the hospital, made possible through its Healthcare@Home program, Brian Holzer, a physician who oversees the program as senior vice president of diversified services, tells Home Health Care News.

“Our goal isn’t necessarily to drop readmission rates,” Holzer says. “The ultimate goal is the ability to manage a population of patients, keep them in the home, and do so in a high-quality manner.”


After several partnerships were forged with various home health, technology and medication companies at the end of 2014, AHN introduced each of its service offerings under one umbrella by April in an effort to achieve such a mission. It was an undertaking that required a joint venture with home health and hospice provider Celtic Healthcare Inc. to effectively form the second-largest such provider in the region*, and a connection with Johns Hopkins Home Care Group to acquire a majority stake in Klingensmith HealthCare and its expertise in home care and medical equipment.

“We realized that if we tried to do it ourselves, it would have taken a lot of capital upfront,” Holzer tells SHN.

Forty transitional care coordinators have been hired and tasked with assessing patients and developing their care plans upon discharge if home care services are required. The utilization of these employees, along with fully integrating all facets of the program, has resulted in a 5% reduction in readmissions within 30 days of discharge, quantified by a $5 million reduction in “unnecessary medical expenditures,” Holzer says.


“We wanted to take out the complexities and inefficiencies of running these in silos,” he says.

The result—a model “truly centralizing all of the services required to deliver home-based care.”

“In a value-based world, if we’re able to save organizations millions of dollars in rehospitalization penalties, this is where the new model is going to be,” Holzer says.

Written by Kourtney Liepelt

*Editor’s note: This article has been updated from a previous version, which erroneously mentioned an AHN partnership with UPMC Home Nursing Agency, which does not exist. We regret the error.

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