A recent article in Home Healthcare Now journal discussed specific approaches to reducing rehospitalizations between transitions in healthcare. With almost 20% of Medicare beneficiaries being readmitted to the hospital within 30-days of discharge, it has become a priority for both acute care facilities and home health agencies to reduce this number to manage costs and improve publicly reported outcomes. High risk patients are those with chronic conditions such as heart failure, chronic obstructive pulmonary disease, (COPD), pneumonia, and diabetes.
The article reviewed The Joint Commission’s analysis of five healthcare organizations that were chosen because of their positive reputations in the home care community.
The following care transition activities were consistently found to achieve positive results:
An initial contact with the patient by home health prior to discharge from the hospital.
Completion of a readmission risk assessment prior to discharge from the hospital.
Initial patient teaching in the hospital that focused on “red flags” for exacerbation of the chronic condition.
A visit within 24 by home health after discharge from the hospital, along with 24/7 on-call availability.
Front-loaded home visits (higher frequency at start and tapered down as condition improved).
Implementation of Integrated Care Management (ICM) Transitions of Care Programs.
Delivery of self-management support and health-literate care.
Use of the teach-back process of patient education.
To support health literacy, use of jargon-free disease and medication teaching and “stoplight” teaching resources (green = action not needed; yellow = take action today; red = take action now).
Comprehensive medication reconciliation.
SBAR communication technique (situation, background, assessment, recommendation) with prompts added to documentation summaries.
At least 9 patient contacts (home visit, telehealth, phone call) within the first two weeks of admission to home care.
Root-cause analysis done on all patients readmitted to the hospital within 30 days of discharge to determine cause and possible actions that could have prevented the readmission.
Use of transitional care nurses to follow the patient from the hospital to home care, along with a multidisciplinary approach.
Comprehensive disease management training for clinicians.
In addition to these specific actions, agencies with successful results made it a priority to ensure that nurses were knowledgeable in infection control practices and home safety, including a focus on medication safety and fall prevention. Overall agencies that practiced focused care transition activities had significant reductions in readmission rates.