Home care providers can help hospitals reduce readmission rates during the critical 30 days following discharge from hospital. As a result, home care referrals are being given with positive patient outcomes in mind. Here are a few ideas for improving patient outcomes and reducing readmission rates:

Use an after-hours answering service...not an answering machine.

Patients who are experiencing an exacerbation want immedate help. Simply being available by phone can often be enough to delay a visit to the emergency room and a potential admission. At a minimum the patient should be able to speak immediately with the home health supervisor during or after office hours.  A hospital re-admission can be avoided by visiting the patient after hours or scheduling a visit the next day.

More Hospitalization Prevention Strategies

1. Make sure the patient has a competent and capable caregiver.

Make sure that the contact information for a capable and competent caregiver is recorded in the patient's chart. In many states this Best Practice is a state regulation.

2. Know which clinical conditions place patients at higher risk.

Congestive heart failure, chronic lung disease, psychiatric issues, cancer, pneumonia, and diabetes mellitus, uncontrolled pain.

3. Make the home health admission visit within 24 hours after hospital discharge early and make sure the patient completes necessary physician follow-ups.

Help patients make appointments and organize transportation as necessary. Regular follow-ups will help reduce the likelihood of adverse drug events (see #8).

4. Take special care when communicating with patients who have language barriers.

Communicating important care instructions to patients and their caregivers is vital to prevention of readmissions. A language barrier can lead a patient to miss vital information and could result in a hospitalization. Check for understanding, find a translator as needed, and overcome challenges to keep in touch with these patients.

5. Request instruction recall from patients and caregiver.

Clear communication with patients is a significant step toward avoiding the cost of preventable readmissions. Care providers can teach an individual how to recognize their own symptoms before they get worse, and which actions to take to prevent worsening of these symptoms. Clear communication is also key to improving patient satisfaction and quality of care ratings.

An example of the benefits of patient communication comes from UCSF Medical Center, where a team of heart failure experts monitored heart failure patients after discharge. The team implemented a strategy of educating the patients about their disease, and using the “Teach Back” method to check understanding. The “Teach Back” method involved asking the patient to repeat what they have learned in their own words. The educational approach helped reduce readmissions for heart failure in senior patients by 30 percent.

6. Reconcile prescriptions as soon as possible after hospital discharge.

According to the American Academy of Family Physicians (AAFP), one in six hospital admissions of older adults is the result of an adverse drug event. More than half of adverse drug events are the result of dosing, and therefore may be preventable. Adverse drug events are more likely as the number of medications the individual is taking increases. Some methods to reduce the risk of adverse drug events include:

    discontinuing medications
    limiting the prescribing of new medications
    reducing the number of clinicians prescribing medication
    frequently reconciling prescriptions
    providing medication reminders
    assisting with administration

Best Practices for Home Health Aide Supervisory Visits

Guidance for Completing M1610 Urinary Incontinence/Catheter Presence