As value-based purchasing makes relationships between home health care agencies and hospitals more important than ever, one home health provider is taking a closer look at how to reduce rehospitalization rates.
The new outcomes-driven model penalizes hospitals for high levels of readmission, causing them to look at their health care partners with a more critical eye, and giving home health agencies an opportunity to prove their value proposition.
Baton Rouge-based Amedisys (Nasdaq: AMED), one of the nation’s largest home health care providers, is working against an industry tide of rising rehospitalization rates with a set of processes to cut readmission rates.
“There are a number of things that any agency can do to reduce a patient’s hospitalization,” Susan Sender, Amedisys chief clinical officer, told Home Health Care News. “Interestingly, as an industry, we’re beginning to see rehospitalization rates climb a little bit. It remains to be seen where we go.”
Sender, who joined Amedisys in September 2016, has helped Amedisys revamp its clinical initiatives, including focusing on reducing remission rates. In the latest efforts by Amedisys to continue improving care quality, the clinical programs team underwent a certification program organized by the National Readmission Prevention Collaborative (NRPC), a nonprofit organization that works to share best practices in population health management.
As Sender noted, the industry is seeing a rise in rehospitalizations as hospitals and accountable care organizations (ACOs) sending patients directly into the care of home health agencies instead of skilled nursing facilities (SNFs) first, Josh Luke, a former hospital CEO and the founder of NRPC, told HHCN.
To buck this trend, Amedisys follows a series of best practices to manage care at home.
1. Ensure strong clinical oversight
Amedisys relies on clinical managers to oversee all aspects of a patient’s care, ensuring communication between physicians and caregivers, as well as coordination of all disciplines providing care.
“At the very grassroots level, providers should make sure that their clinical managers are providing very strong oversight, managing the care that the patients receive, and ensuring that there is continuity of care,” Sender said.
2. Analyze rehospitalizations
Any time a patient does go into the hospital, Amedisys requires a root-cause analysis to be performed to determine why it happened. Important questions to ask, according to Sender, are, “Was there anything we could have done to avoid that rehospitalization?” and “What should we be doing in the future?”
With this data, Amedisys knows how many patient rehospitalizations were avoidable, and can assess specific cases to prevent future unnecessary readmissions.
3. Identify high-risk patients
Home health providers should use internal and external reporting and communication tools to identify patients who are a high risk for rehospitalization, Sender advises. Then, protocols should be developed for that list of high-risk patients, who may require increased levels of communication and monitoring.
Amedisys partners with Homecare Homebase, a Dallas-based health care software company that provides communication and information exchange between office staff, field staff and physicians. It also uses Strategic Healthcare Programs (SHP), a Santa Barbara, California-based software company, to get access to health care data analytics and performance metrics.
Many of Amedisys’ high-risk patients are sufferers of congestive heart failure and chronic obstructive pulmonary disease (COPD)—so the home health care company has recently introduced two new programs aimed at chronic disease management for these conditions.
4. Stabilize first
Amedisys caregivers have found that throwing many disciplines into the home during the first couple weeks of care doesn’t work out well, Sender said. Time needs to be spent stabilizing the resident’s condition before teaching them to be more independent in their care.
“We must make sure that patients are in the right place in terms of their physical condition, their emotional place and their ability to cognitively understand what it is we’re teaching them,” Sender said. “They’re not going to be able to be independent in their care until we’ve stabilized their condition.”
5. Implement patient care conferences
Communication is the crux to avoiding rehospitalizations, according to Sender.
Amedisys performs patient care conferences—meetings between the clinical manager, a representative from each discipline providing care and sometimes the patient’s physician and representatives from other care disciplines. This group discusses the resident’s care, what has been accomplished, continuing goals and anything new going on.
These conferences happen at least once every 60 days for every home health care patient, and more frequently for patients whose condition is unstable or whose care requirements are very complex.
“Patient care conferences are critical—I’d suggest the single most critical activity we can perform to keep those patients out of the hospital and safely at home,” Sender said.
Written by Elizabeth Jakaitis