Prevent Readmissions /Promote Community Stay






Nationwide almost 20% of patients discharged from hospitals are readmitted within 30 days. The Centers for Medicare and Medicaid Services (CMS) has made reduction of preventable readmissions a top priority for the Medicare program. Through adoption of performance measures, financial incentives, and financial penalties, CMS is increasing pressure on hospitals and partners along the continuum to adopt transition-of-care strategies that prevent avoidable readmissions.The CMS Hospital Readmission Reduction Program focuses on six key conditions driving readmissions:

  • Acute Myocardial Infarction
  • COPD
  • Heart Failure
  • Pneumonia
  • Coronary Artery Bypass Graft Surgery
  • Elective Total Hip or Total Knee Replacement
For home-based care organizations, preventing readmissions is an increasingly urgent priority. Use these links to navigate between sections:  Best practice recommendations for each of these strategies are included here. The Resources tab includes more links to evidence and practical tools to support agency activities.

Home health agencies are accountable for preventing readmissions and preventing readmissions after the episode and improving community stay. Here we examine best practices to prevent hospital readmissions. See the Blueprint's Discharge to Community module below for best practices on improving community stay.
 
Home health organizations need to look 'upstream' at hospital and physician referral sources, and 'downstream' to the community to develop coordinated processes to meet patient needs. 
Preventing readmissions requires effective use of agency data and assessment tools to identify patients at risk for readmission from home health and after home health discharge.
  • Upstream strategies will improve transitions of care and help to ensure that home health is the appropriate placement for the patient and that care is coordinated.
  • Downstream strategies offer warm handoffs to community-based organizations that can support the patient and caregivers at home. 
ElevatingHome Best Practices for Preventing Readmissions
  • Identifying patients at risk for readmission through use of standard risk assessments,
  • Scaling home health interventions to meet the needs of high risk patients,
  • Partnering with organizations across the continuum to implement effective transitions of care (including hospitals, ACOs, and community-based organizations)
  • Developing protocols and targeted approaches to prevent clinical exacerbations and address common causes of readmissions, including declines in functional status and pain
  • Developing integrated approaches to refer for palliative care and hospice
  • Proactively planning for discharge to the community
Recommended Best Practices - Detail

Goal: Improve the continuum: hospital handoff to home
Best Practice Interventions
  • Implement hospital partnerships to improve transitions. Value-based purchasing and hospital conditions of participation require them to reduce readmissions and develop patient-centered discharge plans. Use this information to develop a shared strategy.
  • Use standardized transition protocols with hospital partners
  • Collaborate with hospitals/ACO on discharge placement criteria and protocols to ensure home health placements are appropriate
  • Develop hospital / ACO collaborations such as an ‘ED U Turn’ program. This is a collaboration between the hospital and ED to refer patients to home care to prevent subsequent ED visits
  • Develop collaborative protocols for managing exacerbations, e.g. Lasix program with local hospital for CHF patients
  • Adopt routine and transitional care meetings with hospitals and SNF on reducing readmissions
  • Develop direct admit policy to nursing home to bypass ED or acute stays. This will help home health performance on readmission measures but not on 'discharge to community' measures.
  • Educate local urgent care clinics or retail sites on referral to home health as an alternative to ED referral
  • Meet with insurer, hospital or ACO care management teams to understand and coordinate home visiting programs offered by these organizations
Note on Acute Care Placement: Appropriate placement after an acute admission is an important determinant to preventing readmissions. Many patients are discharged to home (often at their own request), either when adequate supports are not in place or the patient’s condition is highly fragile. Home health agencies should work with hospitals and ACOs to develop programs and plans to ensure necessary supports and services are in place for patients discharged to home. New predictive analytics are also emerging that can identify patients at risk for a poor outcome if discharged directly to home.

Goal: Build trust and relationships with referring clinician practices
Best Practice Interventions: 
  • Consider assigning dedicated nursing teams to medical groups to facilitate relationship building
  • Use SBAR by fax or email to make suggestions to MD for treatment instead of sending to hospital.
  • Develop relationship with and recommend a visiting physician practice to visit patients in their home
  • Collaborate with physician groups on billing and supervision to secure home visiting services by physicians or nurse practitioners

Goal: Ensure patients have confirmed relationships with primary and specialty care
Best Practice Interventions:

  • Confirm patient and caregiver knowledge of their practitioners
  • Confirm appointments and other follow up planned after home health discharge
  • Use teachback to ensure patients and caregiver understand who to contact after discharge from home health
  • Note that lack of access to practitioners is a greater barrier for racial and ethnic minorities and for people with low socio-economic status. Consider these populations higher risk for lack of access to care. See the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries and other tools on the Blueprint Resources page.
Top Tip: Provide access to home-based geriatric nurse practitioner or physician services. This may be through staff model, arrangement with local physician / NP group, or hospital partnerships.

Goal: Improve access to palliative care and facilitate appropriate transition to hospice 
Best Practice Interventions:

  • Develop referral programs and processes to assist in identifying and referring patients eligible for palliative care
  • Consider developing an agency-level palliative care program
  • Work with hospital partners to develop collaborative palliative care programs as a strategy to reduce preventable readmissions
  • See also the Blueprint module on Improving the Continuum of Care at the End of Life for detailed recommendations on developing programs for patient-centered home health, palliative care, and hospice hand-offs
  • Assess clinical eligibility for hospice
  • Train home health staff on having discussions with patients and families about hospice
  • Offer hospice RN or social work visit during HH stay
  • Engage home health social worker to review options with the patient and family when an extended home stay seems unlikely
Goal: Understand and address risk factors related to readmission risk
Best Practice Interventions:
  • Improve and standardize the agency’s Risk Assessment process
  • Complete a high risk assessment tool at admission
  • Conduct falls risk assessment and depression risk assessment
  • See the Blueprint's Care Initiation Module for detailed recommendations on early identification and mitigation of readmission risk
  • Adopt protocol to intensify the care plan for patients at high risk including first visit within 24 hours and front loading of visits 
  • Maximize the number of touch points during the first 2- 4 weeks
  • Develop and implement telehealth protocols
  • Offer or arrange nurse practitioner visits for high risk patients or patients with unstable clinical condition
  • Work with referring facilities to improve communication of risk factors at the time of referral. 
Note on Frontloading: Early admission to home health (within 24-48 hours of discharge), and frontloading interventions have become standard protocol for many agencies. Intuitively this makes sense: recently discharged patients are often frail and can easily be thrown off track by a missing medication or frightening system. But, many agencies note that the data does not always support the highest intensity. Many agencies are now using phone calls and other ways to engage the patient as part of their frontloading strategy, rather than applying skilled visits. Agencies should track and evaluate effectiveness of different combinations of skilled, non-skilled, telephonic and telemonitoring visits to determine which frontloading strategies are effective at reducing admissions / readmissions.

Note on telehealth: Many agencies recommend caution in widespread adoption of telemonitoring in home health. Data are unclear as to whether telemonitoring has an impact on reduced readmissions. A 2014 review that examined telemonitoring for heart failure did not see an impact on readmissions (see References section for more evidence). Agencies that adopt telemonitoring should implement protocols to ensure telemonitoring is applied according to protocols, and that the agency is able to collect data needed to determine both clinical and cost-effectiveness.

Goal: Maximize use of data and electronic systems to predict, prevent, track, and evaluate readmissions
Best Practice Interventions:
  • Program electronic ‘alerts’ to clinicians reminding them of high priority activities associated with patient risks
  • Use predictive alerts to flag patients at risk for ED use or readmission to the clinical managers
  • Have management review trends and evaluate use of alerts regularly to identify weaknesses
  • Look for patterns in ED and readmission data (such as correlation with staffing, day of the week, or clinical conditions) that can drive performance improvement interventions
  • Build the data reports into daily, monthly and quarterly quality monitoring processes, and ensure that all staff have information on the agency’s performance
Goal: Adopt Care Pathways that comprehensively address patient needs: universal factors such as pain and function, and clinically specific for patients with certain conditions
Best Practice Interventions:
  • Adopt standards of care or care pathways for prevalent clinical conditions such as heart failure, infection prevention for surgical care, etc. In the protocol, include the agency’s plans for telehealth and emergency care
  • Develop stand order protocols for certain rescue medications (such as Lasix) under specific criteria
  • Work with hospitals and ACOs on common pathways, and consider bringing in other partners as needed for specific expertise e.g. infusion therapy providers. Local payers can help to ensure that collaborators have incentives to be at the table.?
  • Have a physician point of contact as part of the protocol or pathway. That individual should be authorized to intervene quickly to keep the patient out of the hospital. 
Top Tip: Make sure patients and caregivers know what to do if they have problems. For example, use Zone Tools to discuss possible clinical issues and ‘call me first’ posters or information to remind the patients to contact the nurse HHA they are having a true emergency.
 

Goal: Engage patients to help them stay healthy and stay at home

Best Practice Interventions:
  • Train staff on patient engagement
  • Use motivational interviewing to connect patient actions to goals, and to reinforce positive behaviors
  • Consider need for behavioral interventions or behavioral consult for patients with frequent admissions/readmissions related to adherence
  • Implement agency-level multidisciplinary care conferencing to identify specific engagement strategies for high risk patients
  • Develop protocol for hospital or health system-level multidisciplinary case conference for patients with frequent use of ED, admissions, or readmissions
  • Use Social Work referral to link patients with community resources

Goal: Prevent, recognize, and manage cognitive decline
Best Practice Interventions:

  • Routinely screen patients for cognitive decline, and ask caregivers to report changes
  • Use SBAR to consult with physicians about cognitive decline
  • Use specialized home health agency staff to patients with diagnosed cognitive conditions
  • Provide social work consult to connect patient and caregivers to community resources
 Discharge to Community

Home based health care organizations have long worked to reduce hospital readmissions. Now, the Discharge to Community performance measure adopted under the IMPACT Act requires that agencies also anticipate and plan to prevent readmissions after 
discharge from home health. The annually-updated Conditions of Participation also emphasize comprehensive, patient-centered discharge planning.


Related measures - Home Health:
  • IMPACT Act Discharge to Community
  • IMPACT Act Potentially Preventable Readmission
Discharge to Community (DTC) requires helping patients to stay in the community after discharge from home health. DTC goes hand in hand with home health interventions to prevent readmissions during the home health episode. Here we examine home health strategies specific to DTC, focusing on connecting patients to community resources and ensuring that the patient's cognitive and functional status is stable. To be effective, home health organizations will need to look 'upstream' at hospital and physician referral sources, and 'downstream' to the community to develop coordinated processes to meet patient needs. Upstream strategies will improve transitions of care from hospital to home, and ensure that home health is the appropriate placement for the patient. Downstream strategies offer warm handoffs to community-based organizations that can support the patient and caregivers at home.

ElevatingHome/VNAA appreciates input of the expert Discharge to Community Work Group, a joint project of VNAA and the Alliance for Home Health Quality and Innovation

Recommended Best Practices

Goal: create processes for seamless transitions from facility to home health and home health to community
Best Practice Interventions:
  • Develop agency-level transition of care protocols
  • Document the MD visit plan after HH discharge and have agency clinicians facilitate appointment scheduling in advance
  • Identify medication management and refill plan, including how the patient will obtain and pay for medications
  • Ensure patients and caregivers have a plan for symptom exacerbation or urgent care needs (this may be a referral arrangement with advanced practice nurses or home visiting physician service)
  • Ensure the patient and caregiver maintain functional status goals and use rehabilitation services when indicated
  • Use social work or patient navigators to connect at risk patients to community resources to prevent readmission after home health discharge
  • Develop a QI plan around transitions.  For example, see the AHRQ Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings
Goal: Ensure patients have confirmed relationships with primary and specialty care
Best Practice Interventions:
  • Confirm patient and caregiver knowledge of their practitioners
  • Confirm appointments and other follow up planned after home health discharge
  • Use teachback to ensure patients and caregiver understand who to contact after discharge from home health
  • Note:lack of access to practitioners is a greater barrier for racial and ethnic minorities and for people with low socio-economic status. Consider these populations higher risk for lack of access to care. See the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries and other tools on the Blueprint Resources page.
Goal: Prepare patients and caregivers to stay in the community
Best Practice Interventions:
  • Make a social work referral early after home health admission
  • Identify comprehensive social needs: food, transportation, financial means, caregiver capability and ensure a plan is in place before home health discharge
  • Identify community based organizations willing to partner with the HHA on nutrition, caregiving assistance, transportation, and other resources that can help prevention readmissions during and after the home health episode. Examples include:
    • Alzheimer’s Association and Local Chapters of Heart, Lung or other Associations
    • Community Health Centers
    • Food Pantries / Meals on Wheels
    • Housing Organizations
    • Transportation (crucial for clinical follow up)
    • Medication assistance programs - both for financing and picking up medications
    • Protective Services
    • Local Health Department or Office of Aging
    • State Health Insurance Programs
    • Senior Centers and Adult Day Care
    • Volunteer Organizations - respite, peer support, other direct support
    • YMCAs - many offer depression and falls prevention services
Best Practice Example: VNA of Boston uses Community Resource Specialists (CRS) to access community services.  VNA of Boston has 3 CRS employees to patient needs. These individuals are highly skilled non-clinicians who utilize excellent communication skills, mostly by phone and in some cases home visits, to assist the clinician/manager upon request in seeking and securing such resources as Personal Care Assistance, heavy chore service, assistance with IADLs such as homemaking and rides, Lifeline, prefilled medication systems, assistance with Payor applications, and/or specific disease support services. The norm is that the clinician identifies the specific need(s) and makes a referral to the CRS. VNA of Boston reports that the system has been in place for 18 years and has been very, very helpful.

Goal: Improve access to palliative care before home health discharge
Best Practice Interventions:

  • Develop referral programs and processes to assist in identifying and referring patients eligible for palliative care
  • Consider developing an agency-level palliative care program
  • Work with hospital partners to develop collaborative palliative care programs as a strategy to reduce preventable readmissions
  • See the ElevatingHome Blueprint module on Improving the Continuum of Care at the End of Life  for detailed recommendations on developing programs for patient-centered home health, palliative care, and hospice hand-offs
Goal: Prior to HH discharge, facilitate awareness and/or appropriate transitions to hospice
Best Practice Interventions:
  • Assess clinical eligibility for hospice during the HH episode
  • Train home health staff on having discussions with patients and families about hospice
  • Offer hospice RN or social work visit during HH stay
  • Engage home health social worker to review options with the patient and family when an extended home stay seems unlikely
  • See also the ElevatingHome Blueprint module on Improving the Continuum of Care at the End of Life  for detailed recommendations on developing programs for patient-centered home health, palliative care, and hospice hand-offs
Top Tip: Make sure patients and caregivers know what to do if they have problems. For example, use Zone Tools to discuss possible clinical issues and ‘call me first’ posters or information to remind the patients to contact the nurse HHA they are having a true emergency.
 
Goal: Engage patients before discharge to help them stay healthy and stay at home
Best Practice Interventions:
  • Elicit patient and family goals to remain at home and help them understand that their actions and collaboration with the HHA can help the patient stay out of the hospital
  • Use motivational interviewing to connect patient actions to goals, and to reinforce positive behaviors
  • Consider need for behavioral interventions or behavioral consult for patients with frequent prior admissions/readmissions related to adherence
  • Use Social Work referral to link patients with community resources
Goal: Prospectively prevent, identify and manage cognitive decline
Best Practice Interventions:
  • Routinely screen patients for cognitive decline, and ask caregivers to report changes
  • Use SBAR to consult with physicians about cognitive decline
  • Use specialized home health agency staff to patients with diagnosed cognitive conditions
  • Provide social work consult to connect patient and caregivers to community resources
Page updated August 2019