Poor Communication Between Home Health, Doctors Leaves Patients ‘Lost in the Wilderness’

Despite ongoing efforts to provide seamless transitions of care, patients’ journeys from hospital to home still remain full of gaps. Persistent, systemic lapses in communication between doctors, home health providers and patients may be largely to blame.

Continuity in care, when achieved, gives patients greater confidence, engagement and trust in the overall medical care being provided, research has shown. It’s a point that the home health industry and, more broadly, the U.S. health care sector has repeatedly worked to strengthen over the past several years through targeted acquisitions, strategic partnerships and the creation of special positions, such as the transition of care coach.

When transitions don’t go smoothly, the likelihood of re-hospitalizations goes up and patients’ perception of care quality, unsurprisingly, goes way down.


“We’ve been working at this for a very long time, trying to improve transitions of care,” Suzanne Mitchell, assistant professor of family medicine and palliative care at Boston Medical Center, told Home Health Care News. “Even though we’ve done a lot to try to improve our systems of care, for patients and [their family caregivers], things still look the same, and they still feel hazardous, unsafe and transactional in a lot of situations.”

Communication is key

Mitchell, a board-certified physician in family medicine and palliative care, highlighted the experiences, perspectives and outcomes of more than 130 patients navigating complex care transitions as part of a recent Annals of Family Medicine study. After scores of interviews, Mitchell and her fellow researchers identified “uninterrupted care with minimal handoffs” as a main factor linked to patients feeling satisfied with their care transitions.


Other factors included the ability of health care providers to anticipate patients’ needs, to take part in collaborative discharge planning and to offer information patients can act on.

Perhaps the biggest pain point in terms of providing uninterrupted care is a lack of communication between home health agencies and doctors, Mitchell said. That likely isn’t a shock to home health providers, however, as poor communication and care coordination has long been seen as a challenge, particularly within emerging demonstration models.

“At what points in the process do physicians and home health actually speak to each other?” Mitchell said. “We don’t have good channels of communication when handoffs happen in real time, and we rely on documentation that we know is poor.”

In general, even when documentation does have accurate and important information, doctors are frequently overworked or overburdened, unable to thoroughly evaluate a form that a home health agency has faxed over. Previous studies have suggested physicians spend about one minute reviewing home health care plans, and more research is underway to understand how to improve this specific interaction.

“I think what matters is that people on a team know each other and have ways of communicating with each other,” Mitchell, who has worked closely with home health agencies as a practicing physician, said. “If I know my home health care team well, then I can rely on their assessment to carry out my orders.”

Participants who took part in Mitchell’s study reported that too many handoffs and a lack of familiarity during a care transition led patients to feeling they were not known by medical providers. One participant likened the care transition experience to “being [lost] in the wilderness.”

Streamlined communication might be on the horizon as health care shifts toward value-based care, Mitchell said. Not every value-based payment model would serve as a solution, but the bundled payments model, which links payments to multiple services during a single episode of care, might, she said.

“I think that how we deliver care and how we pay for it has a big impact on how well we play the field as a team, how well we engage with each other when patient care is at stake,” Mitchell said. “Every model wouldn’t support communication … but I have seen [evidence of] success when it comes to bundling.”

Fillings the gaps

Physicians often worry about what goes on in their patients’ homes, but rarely have time to follow up themselves. With stronger communication, home health providers can be those conduits between doctors and homebound patients, helping to fill existing gaps, Bruce Leff, professor of medicine at Johns Hopkins University School of Medicine and director of the Center for Transformative Geriatric Research, told HHCN.

For example, nearly 90% of primary care providers worry that their patients are not adhering to medication as prescribed, according to a Quest Diagnostics study on chronic care management. That’s something a home health nurse could easily update physicians on if given the opportunity.

Similarly, about 90% of physicians routinely try to follow up with patients with multiple chronic conditions, but feel like they’re not able to do so to the desired extent, according to the Quest Diagnostic study. Again, a home health caregiver could readily provide that much-needed support, Leff said.

“I think the communication between home health agencies and physicians, in its current state, is, for the most part, deeply flawed,” Leff said. “For folks who are getting skilled home health care services … you think it’s the population where effective, efficient care coordination could actually be useful, but it tends not to happen because of a pretty archaic, burdensome and bureaucratic approach to communication.”

Documentation flaws 

Currently, a main avenue of communication between home health providers and doctors is the CMS-485 form, but that’s riddled with problems, Leff said. For one, the form is “extremely difficult to read” because of its use of technical jargon and tiny print. The form is also problematic because it doesn’t give home health nurses the ability to write down big-picture observations and insights that could affect patient care if relayed to physicians.

The industry has stuck to the form, though, because its recommended by the Centers for Medicare & Medicaid Services (CMS) and unlikely to get home health providers in compliance trouble, he said.

In addition to value-based payment models, coming up with different documentation and reporting means would also likely lead to improved communication between home health providers and physicians, Leff said.

“Communication is hard,” he said. “Creating those lanes for communication is not easy.”

About one-third of physicians frequently feel like they’re unable to address the needs chronic care patients, according to Quest Diagnostics.

“I think the biggest issue is that most physicians don’t have the best understanding of what goes on in a patient’s home,” Leff said. “Most don’t get out to patients’ homes, and I think they don’t clearly understand the capabilities and competencies of skilled home health care agencies, what they can and what they can’t do.”

Written by Robert Holly

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