How A Home Health Provider Slashed Its Readmission Rate By Nearly Half

At-Home Health Care — Sparta Community Hospital’s home health segment — has made successful care transitions a priority in an effort to lower rehospitalizations and ER visits.

Sparta Community Hospital is located in Southern Illinois and is a 25-bed full-service acute care medical facility. At-Home Health Care is a Medicare certified home health agency that serves five counties surrounding Sparta.

For At-Home Healthcare, a successful care transition is one that starts at the day of admission.


“The interdisciplinary team is looking at every piece that the patient is going to need to be successful when they get home, but also providing the necessary information to the next level of care,” At-Home Health Care Administrator Cheryl Adams, told Home Health Care News. “Whether that be the education that has been completed for the patients and families, or history of what’s going on with those patients, medication lists, or specific wound care orders, things like that.”

Effective and efficient care transitions are important because of the negative impacts that can result if the process isn’t handled correctly, according to Adams.

“If we don’t make appropriate transitions, No. 1, you’re putting the safety of that patient and their health at risk, but it also actually costs millions of dollars when that patient is not transitioned properly,” she said.


Indeed, about one in five Medicare patients discharged from a hospital are readmitted within 30 days, at a cost of over $26 billion every year, according to data from the Centers for Medicare & Medicaid Services (CMS).

Some of the common mistakes that lead to poorly handled care transitions are a lack of discharge planning and inaccurate or missing information, such as contact information.

“How are we to take care of that patient if we can’t contact them, or if we can’t find them?” Adams said. “Sometimes we don’t get the appropriate history of what’s going on with that patient and discharge instructions. How is that patient supposed to be following up? What medications are they supposed to be on?”

Within the organization, At-Home Health Care has developed a discharge care coordination team to further improve care transitions.

“We meet monthly, and we’re working on problem solving, it’s a performance improvement project,” Adams said.

At-Home Health Care also has a liaison on staff who is responsible for connecting with patients who are being discharged from Sparta Community Hospital and their family members.

Despite being part of Sparta Community Hospital, the health system only makes up a small percentage of At-Home Health Care’s patient population.

In fact, less than 10% of At-Home Health Care’s referrals come from Sparta Community Hospital, according to Adams.

This is why making sure that At-Home Health Care’s intake staff is aware of what’s needed, and communication with the referring provider, is crucial.

“I have really educated and empowered my intake staff to get the necessary information that’s needed to be transmitted to us and shared with us, but also reminding those discharging facilities, or providers, that in order to make this smooth, these are the things that we need,” Adams said. “If we can’t do that, then it’s going to be a safety issue for the patient and may end up a readmission on your side.”

Several years ago, At-Home Health Care checked in at a readmission rate of over 24%. Over the years, the organization’s focus on readmissions brought that down to 13%.

Adams credits the organization’s telephone program for the turnaround.

“We call it a tuck-in program,” she said. “We’re calling patients on a weekly basis, or when we get further down the line every other week. They still have a contact person, and we’re making that effort to make sure that we’re talking with them to see how they’re feeling. What’s going on, what can we help you with?”

At-Home Health Care has perfected the telephone program outreach by making sure that the staff has a script and clear guidelines for effectively working with patients. Due to this, the company averages between 96% and 98% on patient satisfaction.

Another tool in At-Home Health Care’s belt isn’t something every home health agency will be able to replicate.

The organization’s ties to the community have been an asset.

“I’m a member of the communities that we serve, and I am very passionate about serving that community,” Adams said. “I used to be able to say, ‘I know the clientele that we’re taking care of because they were my parents’ age.’ Now, it’s the fact that these are people that I have grown up with, and have worked with for years, or are acquaintances within the community. I think that truly makes a difference.”

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