Georgetown Home Care Hospital Collaboration Program Reduces Readmissions by 44%

Providing both assistance and assurance to patients after being discharged from the hospital can drastically curb readmissions — and significantly cut health care spending in turn. That was the goal of a Georgetown Home Care (GHC) pilot program launched earlier this year.

GHC’s pilot program achieved promising results. Overall, patients discharged after spinal surgery at Medstar Georgetown University Hospital — a partner in the pilot — were 44% less likely to be readmitted during the period in which GHC was working with the hospital.

Through its role in the pilot, GHC was providing “the eyes and ears within the home,” CEO John Bradshaw told Home Health Care News. And the pilot’s success is clear: When the experimental program ended, Medstar’s readmission rate among the spinal surgery population went right back up.


For that reason, the hospital and GHC — which are not affiliated with one another — have inked a contract to continue the program past the pilot as a “key program.”

“About six years ago, we started seeing the readmission problem being something we thought we could have an effect on, so we took some time and studied it,” Bradshaw said. “I did a fellowship on how to help hospitals prevent readmissions and we developed this program that we’ve been pitching to hospitals for several years. We thought we could be the eyes and ears for hospitals after they discharged patients … [and] this is our first iteration of trying to do that.”

Broadly, GHC and Medstar Georgetown University Hospital were able to collaborate on implementing a plan, with each side offering suggestions the other hadn’t considered. The proven teamwork is yet another example of how cross-continuum collaboration often improves patient outcomes.


GHC hired and trained a team of nurse practitioners specifically for the project. The home care provider would send a nurse into the patient’s home within 48 hours of being discharged, armed with a checklist with the most likely causes of readmission. The checklist provided guidance for the nurse practitioners in their visits with the patients, which continued on a once-per-week basis for four weeks.

Medstar Georgetown University Hospital doesn’t have a particularly high readmission rate in the first place, but GHC was shooting for a double-digit percentage dropoff in response to the program. The result, 44%, was even better than they’d hoped for.

“There’s so much information [come time for discharge], especially with seniors, that you’re hitting them with,” Bradshaw said. “And in many cases, it was just being there to reassure the patient and help them understand what the process was for recovery.”

Typically, the nurse practitioners would help patients with their medication lists, setting out all their prescriptions on the kitchen table. Even if a hospital has good medication reconciliation, often there’s another specialist that the patient is seeing that prescribed the same meds, or incompatible ones.

That peace of mind brought to the kitchen table resulted in an ancillary benefit from the pilot program: patient satisfaction.

“It wasn’t necessarily one of our goals,” Bradshaw said. “They were just so happy to have somebody come out and reassure them that everything is going to be okay and that it’s okay to take their pain meds. The patient satisfaction scores were really kind of off the charts.”

As far as the decision to conduct the pilot with spinal surgery patients, that was the hospital’s choice. They figured the orthopedic and neurological teams there would be well suited to work with GHC in the trial run.

Now, they’ve opened the program to other departments internally, and GHC is looking to expand the program to other hospitals. For the moment, they’ll keep it confined to the Washington, D.C., area.

“I think we’re just going to do it regionally,” Bradshaw said. “We have so many hospitals here. I think we want to continue to refine [the program] and find the right partners. We’ve talked to a couple hospitals that would like to do it, but we’re not sure that they necessarily have the right structure internally to have success.”

According to Medstar Georgetown University Hospital, working with GHC was more cost effective for them than if they would’ve tried to replicate the process themselves.

From GHC’s perspective, however, pairing with a hospital is only worth it if the hospital employees are willing to engage with the program and collaborate with the practitioners.

“We want to be selective and make sure that we’ve got the right partners within the hospitals who are really looking to affect change,” Bradshaw said.

Companies featured in this article: