How Georgetown Home Care Continues to Lower Readmission Rates for Hospital Partners

The Washington D.C.-based Georgetown Home Care (GHC) has yet again lowered readmission rates for a major hospital.

Its readmission success ostensibly began in 2019 when the home care agency first worked with spinal surgery patients at Medstar Georgetown University Hospital. In a pilot program, it reduced readmissions by 44%.

But really, it started when GHC CEO John Bradshaw and his wife first got into the business back in 2012. They kept seeing data on the readmission problem with hospitals. At the time, almost 20% of all patients that were admitted to the hospital were readmitted within 30 days.

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As part of the Affordable Care Act, the government started penalizing hospitals that were above the national average.

Around the same time, Bradshaw participated in a fellowship through the National Hospital Readmission collaborative program on hospital readmissions and wrote a thesis paper on it.

“The idea was to create a program where we would have nurse practitioners advising hospitals on their patients after they were discharged,” Bradshaw told Home Health Care News.

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Georgetown Home Care is a home care agency that provides personal care, respite care, senior companionship services and senior transportation services to the D.C. metro area as well as Montgomery County, Prince George’s County and Northern Virginia.

What Bradshaw quickly found was that “hospitals liked to be paid for health care, but don’t like to pay for health care.”

“My whole premise behind this was kind of flawed because all hospitals are like, ‘Hey, this is a great idea, but who’s gonna pay for this?’” he said.

But then, in 2019, the Medstar Georgetown University Hospital reached out to GHC about doing a six-month trial to lower readmission rates for patients coming out of a specific type of spinal surgery.

“We provided the service to them for free for about six months, and we nailed it,” Bradshaw said.

Fast forward and the program is still running as GHC’s “Key Program,” which has reported positive results for a second year in a row.

The GHC team was able to lower readmission rates at Medstar Georgetown University Hospital to 13.7% for all participants. The hospital has a normal readmission rate of 14.7% and the 2021 national average was 15.5%.

In order to achieve those goals, GHC focused on four key factors: medication adherence, making sure a patient knows their plan of care, home support and assistance with scheduling follow-up visits.

“If you’ve ever been in a hospital and going through getting discharged, you know you’re not at your best,” Bradshaw said. “You’re sleep deprived, you’re on new meds, you’re just not as sharp. A discharge plan is explained to you very, very quickly because they have to discharge so many different patients in a day.”

That process can be overwhelming for seniors. As part of the program, GHC sends a nurse practitioner out to the homes of patients to run through the discharge plan in a more comfortable environment.

“That’s key to this,” Bradshaw said. “Generally speaking, if you can address those four things effectively, you’re going to lower readmissions.”

The biggest challenge for the second year of the Key Program was that Georgetown University Hospital was likely sending some of the most difficult cases for readmission prevention to Bradhsaw and his team.

“[The hospital] probably discharges people in the thousands and we were tracking patients in the hundreds, and so my guess is that they were sending us the patients who were most likely to get readmitted,” Bradshaw said. “Which honestly is fine with us. We’re here to make sure that folks can get home and stay home safely.”

GHC’s resources would not have been used effectively if Bradshaw and his team were being sent patients who were not going to be readmitted anyway, he said.

“You want to use this in the most difficult cases,” he said. “We were hoping we’d still be good at it. The numbers came out strong.”

The first year of the Key Program was in 2020, but Bradshaw called it an atypical year because of all the COVID-19 patients coming in and out of the hospital. Although it handled a smaller patient group size, the Key Program’s readmission rate was around 5.5% to 6% in 2020.

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