Improving Patient Prioritization During Care Transitions Could Halve Re-Hospitalization Rates

Being able to better prioritize patients based on their medical needs and health status upon their hospital discharge can improve home care timing, halve readmission rates and offset staffing challenges.

Those are the main takeaways from a study published last month in the journal Research in Nursing & Health.

“The idea is that if you ensure you’re finding the patients who really need to see the nurse soon after they’re discharged from the hospital, then we’ll be able to streamline processes and help make sure optimal outcomes are achieved,” Max Topaz, an associate professor of nursing at Columbia University Medical Center and a research associate with the Visiting Nurse Service of New York (VNSNY), told Home Health Care News. “To do that, we want to standardize nurses’ clinical decision-making by better integrating technology.”


Medicare policy requires that all patients receive a home visit within 48 hours of their home health agency referral. For unstable or high-risk patients, however, waiting 48 hours could lead to dangerous scenarios, Topaz said.

As part of his study, Topaz worked with VNSNY and other organizations to test PREVENT, a clinical decision support tool built to identify home health patients who need care sooner.

Topaz, who served as lead author of the study, worked to develop PREVENT while at the University of Pennsylvania’s School of Nursing.


Topaz and fellow researchers conducted testing throughout 2016, focusing on 176 VNSNY patients that an area hospital referred to home health services. They used PREVENT to determine prioritization for a control group of 90 patients, but did not share that priority level with home health nurses who influenced visit scheduling. Researchers did share the PREVENT priority determination with nursing contacts for an experimental group of 86 patients.

Experimental group patients who were identified as high-risk received their first home health visit about half a day sooner than those in the control group, contributing to a substantial drop in hospital readmissions, the study found.

Patients in the control group recorded readmission rates of 21.1%, while those in the experimental group saw readmission rates of 11.7%.

“Decisions related to prioritization can differ from agency to agency,” Topaz said. “One nurse in one agency might decide differently about who he or she will prioritize for the first home care nursing visit. We want to answer for that with this standardized decision-making support tool.”

Up to 20% of individuals admitted to home health services nationwide are re-hospitalized during a home health episode, according to the study.

Tools similar to PREVENT are already used in the United States, though some have not undergone rigorous testing, Topaz said. Researchers in Canada have also developed a tool called MAPLe — “Method for Assigning Priority Levels” — but difference in home care environments limit applicability in the U.S. health care system.

“Before we start widely using it, we wanted to gather important evidence on the fact that this tool, PREVENT, is working,” Topaz said. “We’re getting ready for a larger study to test it in a couple of other places, a couple of other hospitals as well, so that’s kind of the trajectory.”

PREVENT was developed using data mining, regression modeling and nurses’ ratings of example patients who were transitioned from hospital to home health care. Overall, PREVENT calculates prioritization using five patient demographic and clinical characteristics related to comorbidities, social support levels and functional status.

In addition to showing the impact of initiating care even a few hours sooner, the study’s results also address the home health industry’s nursing shortage. If agencies can efficiently deploy clinical staff, they can likely continue providing quality despite limited resources.

“The nursing shortage — and not having enough informal caregivers — means we can’t always keep up,” Topaz said. “Tools that help us understand the patient population better … will really help with outcomes.”

VNSNY’s Eugenie and Joseph Doyle Research Partnership Fund at the Center for Home Care Policy & Research funded the study.

Written by Robert Holly

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