Poor Home Health, Doctor Communication Drives Readmissions

A recent study confirms what home health care agencies know all too well: gaps in communication between physicians and home health care providers are detrimental to seniors’ health and lead to hospital readmissions.

Many areas of care are disrupted by communication challenges, including disparities in medication lists, lack of clarity in who is responsible for writing patient care orders, inaccessible hospital records and resistance from clinicians to accept accountability, according to the study conducted by researchers at the University of Colorado Anschutz Medical Campus and published Wednesday in the Journal of General Internal Medicine.

The researchers, led by Christine D. Jones, MD, MS, assistant professor at the University of Colorado School of Medicine, conducted six focus groups with home health care nurses from six different agencies in Colorado. The nurses were asked about their experience caring for patients after they have been discharged from a referring hospital. Some responded with frustration over the difficulty of reaching doctors.


“As a general rule, I’ve been told you’re not to contact the hospitals,” said one nurse in a focus group, according to a press release from the University of Colorado Anschutz Medical Campus on the findings. “I actually got in trouble for contacting the hospital, trying to find out, get more information, trying to track a doctor down.”

Other nurses said that even if they did manage to get in touch with a primary care physician (PCP), they still failed to get the needed information because communication between hospitals and PCPs is also inefficient.

Medical errors occur as a result of these communication failures, including frequently inaccurate medication lists in the hands of home health care providers because there was no coordination between doctors and specialists, according to the research findings.


Additionally, doctors are required to order in-home services, so if a nurse practitioner has been providing care, it becomes difficult to obtain home health.

This complication was exaggerated by the Medicare Pre-Claim Review (PCR) demonstration, implemented in Illinois on August 1, 2016 and paused as of April 1, which required home health agencies to submit claim documentation with a physician signature to a Medicare administrative contractor for audit. Many home care providers voiced complaints about the difficulty of communicating with physicians to get timely documentation that fits auditor expectations.

On a public call with CMS officials before the program was rolled out, home care agencies were already expressing concerns about its implementation. Physicians “have no skin in the game,” and are unlikely to respond with documentation in a timely manner, one questioner argued. Other agencies pointed out they already spend “a lot of man hours” obtaining physician signatures and speeding up this requirement was worrisome.

The study proposed four solutions to the current communication barriers.

1. Hospitals should provide in-home care providers with direct access to electronic medical records and direct phone lines to doctors.

2. Laws should be put in place to allow nurse practitioners and physician’s assistants to write home health care orders. A bill was proposed to do this, but was not acted upon by Congress.

3. Accountability should be established for hospitals to manage in-home care orders until a primary care physicians can take over communications with home health care providers.

4. Better communication methods between primary care physicians and home health care providers should be established to ensure safer transitions.

“As hospitalists, we need to think about what happens beyond the hospital walls and how we can support our patients after discharge, especially when it comes to home health care patients who can be very vulnerable,” Jones said.

Written by Elizabeth Jakaitis

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