Initiate Safe Care

What happens during the first few days a patient is admitted for home-based care has tremendous impact on the patient’s outcome and the likelihood of readmission. 
he Start of Care (SOC) period is critical for building trust between clients and the agency. Initial visits influence patients' experience with care and how they respond to agency interventions. Patients should be evaluated soon after admission to home health to ensure safe, timely, efficient, effective care and to prevent hospitalization or re-hospitalization. During this time, home health professionals conduct assessments, intervene on clinical issues, and schedule follow ups. This is the time to put into place systems to support the patient and caregiver at home, to prevent readmission and ensure successful stay in the community. 

Here we discuss best practices for initiating home-based care - including timely initiation, general risk assessment, falls risk, and flu/pneumonia shots. Best Practice recommendations promote the highest quality of care as well as high performance on home health performance ratings. Use these links to navigate to best practice information on elements of care that should be addressed for every patient in the initial visits: 

Timely Initiation of Care
Risk Assessment
Falls Risk Assessment and Prevention
Delivering Flu and Pneumonia Shots

Elevating Home Best Practices 

Timely Initiation of Care

Relevant Medicare Measures for Home Health:

  • How often the home health team began their patients’ care in a timely manner

Timely initiation of care is important to patient experience, and may also help home health agencies prevent gaps in care that lead to exacerbations and potentially, readmissions. This section includes Best Practice recommendations for improving timeliness of admission while meeting patient expectations.

Timely Admission Top Tip: Consider admissions team where geographically feasible, or dedicated liaisons to ensure consistent admissions processes

Recommended Goal: admit and correctly document admissions within 24-48 hours of referral

Best Practice Interventions:
  • Create a Liaison Team to the hospital responsible for initial patient scheduling, and use central scheduling
  • Use dedicated liaisons to specific referral sources
  • Use admission projections to schedule admission team staffing
  • Establish agency-wide goal to open cases to service within 24 hours
  • Streamline admissions administration
  • Develop clinical algorithms to guide intake, including HHA recommendations for services and rehabilitation
  • Develop and document clear accountability for admissions to promote consistency:
    • Who initiates intake
    • What documentation is needed
    • Who obtains documentation
    • How to document changes in SOC date
  • Identify high risk clients at time of referral or admission
  • Improve authorizations process: Work with insurance payers to develop contract language to allow initial visit pre-approval to avoid delays or non-payment.  Meet with payers regularly. Make sure weekends are pre-approved.
  • Proactively plan for equipment and supplies. Work with referral sources to modify care plan such as (1) changing wound care orders to a dressing that isn’t changed daily (2) change IV med dosing to allow flexibility in admission time (3) Give IV dose just prior to hospital discharge (4) contract with infusion company to do first IV dose at home.
  • Delay facility discharge if patients need equipment that can’t get into the home immediately
  • Audit and monitor compliance with report back to clinical and admission team staff. Develop quality query for patients not admitted within 24 hours to understand factors contributing to the delay
  • Use fax or electronic SBAR communications to engage physicians in a timely manner
  • Provide OASIS training/ audits on accurate coding admissions and to check the referral and discharge dates for accuracy
  • Consider reserving the OASIS assessment for second visit so the patient is not as tired. The agency will need to consider completion of OASIS per their individual policy.
Note: An agency’s approach to admissions will vary by patient demographics, agency size and service area, and availability of staff.  This may determine whether the agency uses a case manager-admissions model or Admission Team model.

Best Practice Model: Admission Team
  • Team manages new admits for 3- 5 visits to establish accurate care plan. After that patient handed off to the case manager.
  • Admission teams based on a 7-days a week model (since 70% of admits are done on the weekends).  HHAs need to schedule staff for when admissions occur, which is the weekends.  Make sure productivity model reflects varying levels of effort by case managers and admissions team.
  • Admission teams are salaried employees, no differentials, no overtime, but are paid at a higher level.
  • Clinicians initiate care within 24-48 hours
  • For some less acute or lower risk patients contact physician for approval of a change in the start of care date after talking with patient/family to assure concurrence and arrange for admission when staffing is available
  • Adopt process for calling MD for new verbal order for new SOC date if delayed
  • Create initiation visit for high risk for readmission patients – this visit requires seeing the patient within 24 hours of hospital discharge
  • Start telehealth on the first visit (when indicated)

Risk Assessment and Risk Management

Appropriate risk assessment ensures organizations identify and stratify those patients at risk for preventable emergency care, hospitalization, falls, or other adverse outcomes. Use the ElevatingHome Blueprint recommendations to improve consistent risk assessment. Target services and interventions to patients at greatest risk. Patients with changing clinical status or identified risks should be reassessed at specified intervals to ensure that the care plan can be updated with needed interventions. 
A standard risk assessment tool helps target those patients at risk of hospitalization so that organizations can identify and stratify patients at certain levels of risk for hospitalization. The risk assessment tool supports an early identification of patients at risk. ElevatingHome recommends tools from the Institute for Healthcare Improvement for their simplicity. There are no risk assessment tools with validity and reliability specifically targeted to the home care setting.
Helpful Hint: Use a home health hospital liaison to identify high-risk patients and the patients’ level of engagement and understanding prior to discharge.
Goal: Tailor intensity of visits and interventions to the risk level of the patient, and measure impact through patient experience, readmissions, and ED use
Best Practice Interventions:
  • Adopt and use a standard tool at the initial admission evaluation to determine risk of hospitalization. Evaluate if the patient needs a second visit based on moderate to high risk of hospitalization. Patients identified as high risk should also receive a second visit within 48 hours of discharge from the hospital. High risk patients are those at risk for hospitalization, including heart failure and COPD patients, as well as those patients on high risk medications. 
  • On the first or second visit, determine if the patient needs frontloading of nursing visits in the first two to three weeks.
  • Document visit frequency on the patient plan of care.
  • Determine if the patient would benefit from telemonitoring (if available) based on diagnosis and incorporate into plan of care.
  • Determine organizational barriers to frontloading during the first two visits and for the first two to three weeks for identified patients. Include staffing needs in this determination.
  • Educate all staff on use of risk stratification tools, confidence ruler, zone tools and high risk medications.
  • Educate all staff about the importance of this practice to get staff buy-in for the practice to be implemented successfully.
  • Monitor plans of care, track results (readmission rates) and communicate outcomes to all staff.
  • Measure productivity in such a way as to allow the same clinical team to see patient over the first two weeks.

Strategies to Manage Risk

Goal: Connect patients and caregivers to follow up care, and ensure they have information and a plan to access this care
Best Practice Interventions:
  • Implement a process to identify responsibility for making an appointment and communicating information to patient, family and staff.
  • During the first visit, address the need to make an appointment with the physician for follow-up.
  • Discuss barriers to making a follow-up appointment
  • Ask patient / caregiver to explain how they will get to the appointment, and connect to social work or transportation resources if needed
  • Discuss the use of a personal health record as a tool to help patients engage in their own health care.
  • Use coaching as an approach with patient/caregiver during visits subsequent to follow-up to make an appointment with the MD'  or other clinician, asking them to 'teach-back' reasons for the appointment and their plan
  • Implement a process for patients that were referred from an MD/clinician office (that have not been in hospital).
  • Incorporate changes in the medical record.
 Helpful Hint: Add a question in telehealth or nursing documentation software to verify MD appointment and visit.

Table 1 below summarizes Initial Interventions in Home Health Episodes
Table 1: Initial Interventions in Home Health Episodes
Complete Admission Requirements
  • See all patients for first visit within 24 hours of institutional discharge or referral.
  • Complete all admission requirements, including consent form. Determine whether the patient had a face-to-face form, physical examination requirements and assess their physical condition. Begin OASIS assessment.
  • Review the admission day documentation--specifically for certain OASIS items.
  • Initiate second contact within 24 hours after the first contact or 48 hours from admission from institution or referral. Follow up on uncompleted items from first day of admission.
  • If high-risk, do second visit within 48 hours from hospital discharge.
  • By the second visit, complete an OASIS assessment and develop a care plan based on these findings.
Conduct Risk Assessment
  • Determine if the patient is at high risk for readmission or falls
  • Ask the patient about prior risk hospitalizations within the past year.
  • Use tools to determine if the patient is safe until the next visit.
Implement Risk Management Strategies
  • Initiate frontloading (with a minimum of three visits in one week) for high-risk patients
  • Perform medication reconciliation
  • Address functional status and pain as falls management interventions along with other falls prevention activities
Develop Collaborative Clinical Intervention Plan
  • Assess clinical status and all clinical indicators previously assessed. Discuss clinical findings from first visit with the patient.
  • Ask the patient about follow-up appointment with physician.
  • Identify signs and symptoms of exacerbation by detecting a change in condition and determine if the patient has an understanding of symptoms and knows what to do.
  • Develop and utilize an emergency care plan (Home Health Quality Improvement emergency care plan).
  • Determine the presence of unresolved issues with physician and follow up for resolution
  • Begin the process for planning transition to community
Assess Patient and Caregiver Knowledge While Setting Expectations for Patient Experience
  • Ascertain patient’s knowledge of clinical conditions and when and who to call for help utilizing the stop light tools and zone tools and teach back method.
  • Review patient/caregiver understanding of medications, how and when to take medications as well as the purpose of each medication. Discuss whether patient has all medications in the home and recommend patient use medication log.
  • To promote engagement, determine the patient's confidence in their knowledge and ability if change occurs, using a confidence ruler.
  • Begin education in disease process, use of personal health record/log using teach back method and reinforce previous teaching
  • Determine if the patient has a follow-up MD appointment in 7-10 days and ascertain whether the patient has a means of getting to the MD appointment. Begin coaching on the need for follow-up.
  • Review emergency care plan with the patient.
  • Review how to reach the office and the next visit to the patient in the home.
  • Ask the patient open-ended questions about how they are feeling and whether there is anything else they need or would like to know.
  • Assess patient caregiver’s ability and understanding of medications
  • Reinforce education about disease-specific change and exacerbation in condition. Regularly review zone tools or stoplight tools and reinforce emergency plan
ElevatingHome Best Practice: The initiation visit is the first visit to be made within the 24 hours of discharge from an institution or referral. The second visit is to be made within 24 hours of the first visit for patients at high risk. Level of risk is evaluated using a risk assessment tool. The recommendation is to use the Institute for Healthcare Improvement two questions tool for its ease of use. Patients scoring at moderate or high risk should be considered at risk.
Falls Risk Assessment and Falls Prevention

Relevant Measures - Home Health:
  • How often the home health team checked patients’ risk of falling
  • IMPACT ACT: Incidence of Major Falls
Patient falls are the most common cause of nonfatal injuries and hospital admissions for trauma for seniors. According to OASIS data, in 2012, 1.4 percent of home health patients were hospitalized due to an injury caused by a fall. CMS is holding hospice and health agencies accountable for preventing patient falls. Home Health Compare includes one measure of falls risk assessment. More importantly, the IMPACT Act requires home health agencies to be evaluated on their rate of major falls with injury, a measure CMS will be testing for public reporting over the coming years. Falls risk is an OASIS indicator and an IMPACT Act measure. 

Table 2 summarizes home health and hospice interventions to prevent falls.
Best Practice Strategies

Goal: standardized fall risk assessment on every home health and hospice patient, with a falls prevention plan implemented for patients at high risk. 

Best Practice Interventions: 
  • A falls risk assessment is completed as part of the initial assessment by team members of the IDT.
  • Build assessment tools into electronic records
  • Use prompts to ensure any findings are acted on
  • Develop protocols for referring patient to PCP or specialty care if at high falls risk
  • Implement an agency-specific process is in place for accurate/reliable occurrence reporting, auditing, tracking and trending of falls metrics
  • Collaborate with community based organizations that can support falls prevention interventions
Goal: Maximize patient's functional status as a falls prevention and readmission risk reduction strategy
See Blueprint Module Maximize Function for more details

ElevatingHome Best Practice: A multifactor, standardized falls risk assessment will be done on each patient over age 18 as part of the initial evaluation; the physician-ordered plan of care includes patient-specific interventions tailored to the specific identified risk factors on the falls risk assessment. Interventions are tailored to the identified specific risk factors.  
Table 2: Addressing Risk Factors for Falls at Home
Risk Factors for Fall Preventive   Interventions
Incontinence Full RN assessment including type of incontinence, medication implications, teaching opportunities, e.g., Kegel exercises
Visual impairment OT referral for environmental modifications
Impaired functional mobility PT, OT, RN, MSW assessments based on specific dysfunction and need for personal care support
Environmental hazards OT, PT referrals and room-to-room recommendations
Poly pharmacy RN medication management with MD and pharmacy consultation focused on high risk medications, duplicative therapy, and clarification of current prescriptions and timing of doses to help reduce risks
Pain affecting level of function RN for complete pain assessment with non-pharmacological interventions and pharmacological interventions if needed
Cognitive impairment Referral to speech therapy if indicated. These patients often need the assistance of home health aides to help family caregivers. Medical Social Work intervention should be focused on identifying volunteer or paid home health aide services to help prevent falls by providing safe assistance with all ADLs.
Pain Pain is a falls risk factor since it has a negative effect on a patient’s level of function. Non-pharmacological interventions are preferred from a falls risk perspective but pharmacological interventions should be used with caution if necessary.
Recommended Resources: (see also Resource page)

Relevant Medicare Measures - Home Health:  

  • How often the home health team made sure that their patients have received a flu shot for the current flu season

  • How often the home health team made sure that their patients have received a pneumococcal vaccine (pneumonia shot)

Delivery of flu and pneumonia shots is an important safety and prevention strategy.  Pneumonia is deadly and preventable. There were approximately 50,000 deaths from pneumonia in the U.S. in 2010, and there are 1.2 million hospitalizations for pneumonia each year. However, only 62 percent of those 65 years of age and older had received a pneumonia vaccination (CDC, 2013). In addition, home health agencies are accountable for ensuring eligible patients receive a flu shot each flu season. The Home Health Compare measure, "How often the home health team made sure that their patients have received a flu shot for the current flu season," is used in calculation of Home Health Star Ratings.

ElevatingHome Best Practice: As part of an admission evaluation, all patients will be assessed for flu and pneumonia vaccination status. Use the 'ASSESS ACCESS AND ADMINISTER' agency assessment form to assure that protocols are in place for procedures for administration, storage, safe transport, standing orders, patient refusals, and monitoring of program.

Goal: documentation of flu shot (and pneumococcal) at transition and intake and increase vaccine acces

Best Practice Interventions:
  • Ensure buy in from the CEO & the board stressing the importance of flu/PNE immunizations
  • Obtain standing orders in August for flu vaccine (in states that permit it)
  • Include mandatory date of flu shot field on referral and intake forms
  • Make flu/pneumonia part of initial assessment, recertification and discharge
  • Incorporate information into EMR or designate centralized easy to locate place to document last flu vaccine date
  • Develop protocol to get order for vaccine if not provided and develop referral arrangements to assist the patient in getting a vaccine from the PCP, retail clinic, public health clinic or other site
  • Implement a designated 'vaccine day' with a dedicated nurse providing vaccines to all homebound patients in a service region in need of flu or pneumonia vaccines. Obtain orders and consent as needed in advance. Having designated day and staff will simplify documentation and vaccine transportation.
  • Adopt routine data query to identify patients who have not received the flu vaccine
  • Designate a staff member to call MD and ask if patient has had flu vaccine if patient does not remember date of last flu shot
  • Use the state vaccine registry and take the vaccine to current patients as part of their visit
  • Educate clinicians on meaning of the flu vaccine OASIS question and meaning of “episode”
  • Routinely assess OASIS accuracy documenting the immunization in the history screen and accurate coding of the M question on TIF and discharge
Goal: reduce knowledge barriers of patients and staff that influence refusals
  • Patient lack of knowledge on need for shot
  • Staff not understanding the importance of patients receiving the flu shot
  • Patients refusing-“it made me sick”
  • Patient does not recall when they had the flu shot.
  • Clinician’s personal beliefs of the efficacy of flu and other immunizations.
Best Practice Interventions:
  • Provide on-going staff education on compliance and importance of the annual flu vaccine (for patients and for staff)
  • Educate staff on the different types of immunizations with a focus on Flu/PNE including risks associated with vaccination compared to risk for non-vaccinators
  • Offer web-enabled refresher education for all staff on flu/pneumonia in late fall
  • Offer competition or incentives for staff vaccinations so staff can be role models for patients
  • Create or use FAQ handout for patients addressing common vaccination concerns
  • Develop policies for staff requirements for flu and pneumonia vaccination, and monitor staff compliance during the flu season
Note on Standing Orders: Standing orders have been proven to be an effective organizational intervention tool to improve vaccination coverage rates among adults. The Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) recommends the use of standing orders for pneumococcal vaccination. Here you will find an electronic version of the Standing Orders for Administering Pneumococcal Vaccine to Adults 65 Years of Age and Older, along with a standing order template for adult influenza. More information, including clinical resources, patient and provider information, and other resources are available at

Recommended Resources:
Page updated August, 2019