Home-based care transition programs reduce readmissions

Now that hospitals are being held responsible for what happens to a discharged patient, health care providers are beginning to use higher level clinicians—even physicians—to make home visits for high-risk patients.

Two healthcare systems are developing and deploying home-based care transition programs to improve post-discharge care outreach.

Steward Health Care System of Boston is taking holistic approach by using “community health workers.” These workers, under the direction of clinicians, are trained to assess a patient’s home situation and ensure people are taking medications and have transportation for their future physician appointments. If social support isn’t adequate, workers teach patients how to leverage community resources for their benefit.

“Our clinicians often don’t come from the communities they serve,” said Dominique Morgan-Solomon, Steward’s director of care management. “It’s really about retraining our physicians, nurses, pharmacists, and nurse practitioners to have a much better understanding of who they’re serving.”

Hill Physicians Medical Group is using non-traditional methods to reach patients at home. In lieu of traditional home health services, the San Ramon, Calif. medical group is partnering with home health agencies on one-time visits with a specific focus on Miles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealthinterventions to prevent readmissions. Hill also has a program for chronically ill patients where a home-management physician works with the patient’s primary care doctor to manage their care in the home.

Hill and Steward both are making additional efforts in managing transitions to skilled nursing facilities (SNFs). The same best practices used for transitions to the patient’s home are being applied for those heading to SNFs. Both systems measure SNF clinical performance, quality of their relationships with physicians, and the SNFs’ desire to improve care. Hill Physicians has home-visiting physicians perform rounds in selected SNFs for high-risk patients.

And like all other programs, organizations involved in care transitions must share patient data, electronically if possible. A great way to do this is through public or private health information exchanges.

In a coming post, we’ll outline how to measure care transition success and how to use those analytics to continually improve programs.

To read more about in-home outreach programs, download the white paper:  “Preventing Patient Rebound: Value-based Care Organizations Should Focus on More Than Just Readmissions.”

Miles Snowden, MD, Chief Medical Officer, Optum

One thought on “Home-based care transition programs reduce readmissions

  1. At Connecticut Community Care, Inc., we are having success in reducing readmissions and increasing access to community services through care transition services that include coaching, home visits and phone calls. We implement the Care Transitions Intervention with both social service and nurse coaches. We also have care transition nurses who work with high risk individuals dealing with multiple chronic health conditions. They are available to accompany the individuals to post-transition medical appointments (or to the SNF) and facilitate communication, reinforce health education and enhance self-management. The ability for individuals, families and care transition staff to have open communication (through electronic health record or other means) with the primary care provider is critical to success.

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