Medicare rewards HHAs for LOW hospitalization rates, and punishes HHAs with high rates. For Medicare (and all payers for that matter), re-hospitalizations imply substandard care.
'Why was the patient discharged in the first place if they need to be hospitalized again?'
The reason for Medicare's concern? Re-admissions cost taxpayers BILLIONS of dollars a year. Medicare even created an initiative to REDUCE hospitalizations under the Affordable Care Act, the Hospital Readmission Reduction Program (HRRP).
First - if a patient is clinically unstable, return them to the facility from which they were discharged. It is BOTH the referring party AND the receiving party to make sure the patient is safely transferred from one provider to the next.
You WANT the patient/caregiver to report ANY AND ALL CHANGES!!
The teachable patient or caregiver IS YOUR BEST ALLY in preventing hospitalizations!
The teachable patient/caregiver role as watchman will be the clinician's best strategy for avoiding acute care AND for achieving a timely and successful discharge.
Now that the teachable patient/caregiver is calling to report any new or exacerbated symptom, your live answering service or receptionist will alert the clinician of the patient's urgent need and an emergency home health visit can be made.
You're inviting a hospital admission...right? If patient can't talk to an Agency representative immediately, s/he may have no choice but to head to the nearest ER.
Especially if your recording says "If this is an emergency, call 9-1-1''.