One in five elderly patients is readmitted to the hospital within 30 days of leaving, creating Medicare costs in excess of $17 billion each year. To rein in those costs, payers are embracing outcome-driven reimbursements in which high readmission rates bring stiff penalties.
Desperate to avoid both readmissions and penalties, hospitals and health care networks are increasingly assessing their home health care partners with a more critical eye.
While this means home health agencies must be prepared to prove their success in minimizing readmissions, it also presents an opportunity for agencies to separate themselves from the competition – if agencies are forward-thinking enough to arm themselves with the right data.
Indeed, home care agencies are incentivized to avoid readmissions: An agency’s star ratings on CMS’ Home Health Compare website are determined in part by readmission rates, which affects the agency’s reimbursement levels.
As a result, it’s critical agencies identify patients with the highest risk of readmission and find ways to reduce avoidable hospital readmissions.
Identifying Patients With the Highest Readmission Risk
Although many clients benefit from home health care, a subset will always be at risk for readmission. It can be helpful to start by identifying at-risk clients, so that steps can be taken to minimize the likelihood of readmission.
Look for clients who experience:
- Language barriers or a difficulty understanding instructions. A client’s failure to understand care instructions almost always leads to noncompliance. Caregivers should check for understanding by having the client repeat back instructions in their own words.
- High-risk environments. When readjusting to life at home, clients may find their home presents new risks, such as fall hazards and access difficulties. Home care agencies should proactively identify potentially dangerous situations and develop a plan to mitigate those risks.
- Lack of medication management. Studies show more than 30% of hospital admissions in the elderly is due to an adverse drug event. Providers should reconcile medications frequently and provide medication reminders to minimize potential adverse reactions.
- High scores on predictive data. As home health providers collect critical Outcome and Assessment Information Set (OASIS) data — like medication management, pain, and functional outcomes — they can analyze the results to identify clients who may be at risk for readmission.
- Too much activity. Clients who are encouraged to do too much, too soon often don’t do well at home following a hospital discharge. Providers should first ensure the client is stable at home before adding additional care disciplines, like physical therapy.
- Caregivers who lack training. Caregivers often need to be able to provide a range of services. Clients whose caregivers underwent an intensive training program that included CPR and infection control experienced 24% fewer emergency room visits in the first year after the training and 41% fewer visits in the second year.
Steps to Reduce Readmission Rates
It’s important for home care agencies to not just monitor a client’s physical health but also social and mental well-being. By approaching care holistically, providers can improve the quality of care and outcomes — and, in turn, reduce the risk of readmission.
Agencies have multiple tools at their disposal to accomplish this:
1. Improve communication among care team members. Communication is key to keeping clients safe at home and preventing readmissions. Particularly when it comes to at-risk clients, the entire care team — including the clinical manager, care providers, and the client’s physician — should be involved in regular, ongoing, and documented conversations that address the client’s treatment plan, accomplishments, future goals, and more.
2. Use sensor technology. Because agencies need to be able to react quickly in emergency situations, installing sensor technology in the homes of at-risk clients may be a good move.
These sensors send the agency real-time alerts of changes to health and daily activity, such as detecting falls or recording the amount of movement in a room. Insights like these can also help agencies implement interventions in the home before conditions deteriorate to the point readmission is required.
And the results are promising: Seniors using sensor technologies experience nearly half the amount of emergency room visits and hospitalizations compared to peers without it.
3. Establish procedures that ensure strong clinical oversight. Clinical managers oversee all aspects of a client’s care and facilitate communication between physicians and caregivers, ensure continuity of care, and coordinate the disciplines delivering care. Their intimate involvement in client care is essential to positive outcomes.
Implement technology to track clients and mitigate risk. Care Delivery Management solutions with robust reporting options empirically demonstrate how home care improves client well-being and reduces readmissions. This data benefits not just the clients and their families, but it can also show positive outcomes to potential referral sources.
Electronic health record solutions also provide the daily clinical and operational support home care agencies need to keep clients healthy at home while simultaneously identifying at-risk clients through online questionnaires and provider documentation.
4. Analyze reasons for readmissions. Identifying the cause of a readmission and understanding what could have been done differently helps agencies determine which rehospitalizations were avoidable (an estimated 75% are) and how to prevent future recurrences.
Home care agencies are a vital part of the care continuum and play an increasingly important role in reducing overall costs by preventing hospital admissions. By having a strong understanding of which clients are at risk of readmission, home care agencies are well-positioned to be a meaningful partner for hospitals by improving patient outcomes and reducing readmissions.