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Of course, once the transition has gone smoothly from the hospital to the home care agency, it’s up to the home care providers to keep the patient from being re-hospitalized. Below is a list of best practices that home care clinicians can follow to improve the patient’s outcomes and reduce the risk of readmission.

  • Review the care plan with the patient until he or she completely understands it, and attends all follow-up appointments with his or her primary physician.
  • Ensure that both the patient and the caregiver recognize signs and symptoms that are new or worsening and how to respond to them and who to contact.
  • Confirm that the patient has personal health records to facilitate communication between all providers. Some hospitals offer these patients “life packs.” Your agency may develop these resources as a great tool for the patient.
  • Ensure patient/caregiver has proper medication regimen and that medicines are set up correctly.
  • Continually educate and engage the patient in their care. Teach them in easy to understand terms what they can do to mange their own care and improve their outcomes.
  • Identify and encourage support systems for the patient. E.g. family members, outside caregivers, or support groups.
  • Identify patient comorbidities. Certain conditions, such as heart failure, make readmissions more likely. But more often the readmissions occur due to comorbidities.
  • Front-load visits in the first 72 hours after discharge, and continue phone monitoring as visit frequency decreases.
  • Encourage the patient to visit urgent care centers instead of an ER when incidents are not life threatening. This will not reflect negatively on your outcome measures, and it will save the patient money.

Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures. The Medicare Payment Advisory Commission estimates up to 76% of readmissions within 30 days of discharge may be preventable.

Ultimately, in an effort to turn this unnecessary spending around, home healthcare will play a major role in care transitions, functioning as the transition coordinator for hospitals. Their attention to detail will help reduce the number of readmissions, and ultimately lead to improved patient outcomes.