Right at Home Helps Lexington Medical Slash Its Readmission Rate

An ongoing partnership between a local home care agency and a well-known hospital is proving just how valuable non-medical services and supports truly are.

Under a home-based care program launched in 2016, West Columbia, South Carolina-based Lexington Medical Center has been working with the area’s Right at Home agency to help complex patients transition out of the hospital and avoid costly readmissions.

When the program first started, the 438-bed hospital had a readmission rate of about 30% for the population of complex, chronically ill patients eligible to partake in the program, Lexington Medical Center Director of Medical Social Services Katherine Watts told Home Health Care News.


By the end of 2018, that readmission rate plummeted to 17%. That figure had been even lower, according to Watts, but one fluke month with more readmissions than typical increased it slightly.

“We are providing up to 20 hours [of non-medical home care services] within the first 30 days of discharge from the hospital,” she said. “It’s really in line with hospital care transitions and trying to create new transition [models] for patients leaving the hospital and going back into their homes, with maybe a need for a little more support than your traditional post-acute care services like home health care.”

As part of the program, a team of licensed social workers from Lexington Medical Center first identifies eligible patients, who can then opt-in to receiving non-medical home care services from Right at Home for free. Lexington Medical Centers takes care of all costs, thanks to annual grant funding from The Duke Endowment through 2020.


Initially, Lexington Medical Center targeted exclusively patients diagnosed with heart failure and one or two other chronic conditions. After seeing solid results, the hospital expanded the program to be more inclusive.

After patients elect to participate in the program, they meet with Right at Home staff before their hospital discharge, go over a general assessment and formulate a plan of care for once they’re home.

That plan of care also factors in possible home health providers and the services they bring to the table, Charles Brown, owner of the Columbia Right at Home agency, told HHCN.

“It’s really been a team effort,” Brown said. “Lexington Medical has navigators, people who are really involved in these high-risk cases. Of course, our caregivers are on the ground. Then you have home health [providers] involved as well, and they have certain criteria they have to meet in order to become part of this program. There are a lot of special requirements to do this.”

Once a patient is home, a team consisting of a Right at Home caregiver and a representative from Lexington Medical Center hold weekly face-to-face meetings.

Good for business

Accredited by the Joint Commission and licensed by the state of South Carolina, Brown’s Right at Home agency has been serving the counties of Lexington, Richmond and Kershaw for nearly 15 years.

The agency has about 155 caregivers total, with a staff that also includes registered nurses and social workers. That robust infrastructure has helped the agency handle the complex cases sent its way from Lexington Medical Center, according to Brown.

The biggest bottom-line impact the Right at Home location has seen from its collaboration with Lexington Medical Center — less than five minutes away — has been linked to building its brand and developing its reputation throughout the community.

The agency provides a discounted rate for the cases it receives through the program.

“When we’re associated with Lexington Medical Center, which is a premier hospital in the state, and The Duke Endowment, it really helps a lot in terms of business,” Brown said. “You’re kind of judged by who you associate with.”

Additionally, the Right at Home’s caregivers have gained unique experience and expertise working with individuals who require a heightened degree of care, Brown added.

Lexington Medical Center is the anchor of a vast network that includes five community medical centers, the largest skilled nursing facility in the Carolinas, an Alzheimer’s care center and more than 6,500 health care professionals. The medical center itself has one of the busiest emergency departments in the state, treating nearly 85,000 patients each year.

About 500 patients have participated in the hospital transition program so far, with an opt-in rate of roughly 70%, according to Watts.

“This is hard work,” she said. “This is not your typical non-medical home care work.”

Based in Omaha, Nebraska, the Right at Home franchise system overall has more than 500 U.S. locations.

‘A no brainer’

The partnership between Right at Home Columbia and Lexington Medical Center reflects the health care sector’s shift toward the home. Throughout the country, hospitals and health systems are looking to forge similar partnerships with medical and non-medical home care providers alike, in part to avoid financial penalties for readmissions.

But finding a willing hospital partner isn’t always easy, Mike Brown, vice president of operations for Right at Home nationwide, told HHCN.

“We’ve worked with another hospital system in the past,” said Brown, the son of Columbia Right at Home owner Charles Brown. “You can bring all the data in the world, but if the hospital system you want to work with doesn’t have the right mission plan in place and isn’t doing it for the right reasons, it really doesn’t matter. At the end of the day, a lot of these hospital systems will just ask, ‘Who’s paying for it?’”

That may change moving forward, he acknowledged, especially as the Centers for Medicare & Medicaid Services (CMS) realigns its goals around home-based care.

“I think it’s an indicator of where things are heading,” he said. “Let’s face it — CMS wants people to go home. Everything is shifting toward home-based care. If you can have a non-medical aide in place and pay a non-medical home care company a small fraction of what you would pay a rehab facility or a skilled nursing facility, basic math says it’s a no brainer.”

Other Right at Home partnerships with hospitals include a past arrangement with Forsythe Hospital and a Winston-Salem agency.

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