How Health Systems Can Use Home Care to Reduce Readmissions

When integrated into the continuum of care, home health helps ensure that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.

Stakes are high with hospitals and health systems facing financial penalties under Medicare's Hospital Readmission Reduction Program for a half-dozen conditions including heart attack, pneumonia, and coronary artery bypass graft. Beyond the HRRP penalties, readmissions increase total cost of care.

As a way to address the readmissions challenge, savvy healthcare clinical leaders at health systems can use home health divisions to reduce hospital readmissions. When properly integrated into the continuum of care at health systems and hospitals, home health becomes a pivotal component of ensuring that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.

Data shows home health services can reduce readmissions:

• Recent data from Paramount—a health insurance company affiliated with Toledo, Ohio–based ProMedica—shows that patients who utilize home health services within 14 days of discharge from an acute care facility are about 25% more likely to avoid a readmission within 30 days of discharge.
   
• In a systematic review of heart failure patients published in the Annals of Internal Medicine, home nursing visits reduced readmissions and mortality for as long as six months.
   
• In an observational study published in the journal Health Services Research, a combination of home health services and clinician visits decreased probability of readmission by 8%.
   
• In a study published in the Journal of Post-Acute and Long-Term Care Medicine, patients discharged from skilled nursing facilities to home care with a home health visit within a week of SNF discharge had a reduced hazard of hospital readmission (adjusted hazard ratio of 0.61).

In coordination with a health system's hospitalists and primary care physicians, home health divisions can help avoid patient readmissions by deploying nurses, physical therapists, and personal care attendants into patients' homes after discharge. In addition to skilled nursing and physical therapy, some home health divisions perform infusions, which offers a relatively high-cost service in a low-cost setting.

Home health provides services that can keep patients from having to return to a hospital, says Bob Pritts, MHA, president of SSM Health at Home and Post-Acute Services, a division of St. Louis, Missouri–based SSM Health. "Most patients want to go home, they recuperate better at home, and home health gives them the opportunity to have the option to go home while still getting the care that they need."

SSM Health at Home offers a robust set of services that helps prevent readmissions, he says. "We do wound care, infusion, [and] a number of procedures in the home that have become regular practice. It's all designed to avoid the patient having to go back to the hospital."

Teamwork helps
 

To avoid readmissions, a team-based multi-disciplinary approach is important, Pritts says.

"If I have a personal care attendant who goes into the home to help with a shower, if she sees something with the patient, she calls the nurse. If I have a physical therapist in the home and they see an issue, they can call the nurse; or the nurse can call physical therapy if the patient is having trouble with balance or with gait. Everybody who is involved with patient care needs to assess that patient every time they come into the home," he says.

Multi-disciplinary teamwork is indispensable to avoid readmissions because no single team member is in the home every day.

"Nursing comes in once a week, and it's hard to identify a problem in visits once per week. Home health aides can be in the home twice per week, and physical therapy is in the home one-to-three times per week. So, you have multiple people in the house and they are all taking care of the patient," Pritts says.

SSM Health at Home care teams also coordinate care with the patient's primary care physician and specialists based on patient needs.

Within a year, the care coordination process will become more technologically advanced, he says. "We are in the process of doing a conversion from our postacute EMR to Epic, which is what the rest of the health system has. Once that is completed, physicians will be able to follow their patients no matter what level of care they are in, as long as there is a medical record and it is documented."

Cost and quality
 

Home health is a crucial element of limiting readmissions at ProMedica, says Steve Cavanaugh, MBA, president of the HCR ManorCare division of the health system.

"Home care is a critical link. When folks go home, often they are not fully ready to care for themselves, or they have rehab needs and nursing needs to fully complete their recovery. Home health plays an important role because if needs are not met, the patient is likely to suffer a setback and go back to the hospital or another care setting," he says.

ProMedica views home health as an opportunity to lower costs and improve clinical outcomes in the post-acute realm, says President and CEO Randy Oostra, DM, FACHE.

Home health is a way for health systems to help bend the cost curve on the local, regional, and national levels, Oostra says. "When you start thinking about general trends in healthcare—affordability and costs of healthcare in America—there is a cost differential between treating patients in a hospital and treating patients in a home setting."

ProMedica acquired HCR ManorCare this year. The division features 110 hospice locations across the country, about 30 home health locations primarily in the Midwest and Mid-Atlantic states, and dozens of SNFs.

Cavanaugh says a primary goal at HCR ManorCare is to become an integral component of ProMedica's continuum of care. "We see ourselves as being part of an integrated care delivery model—using home health and hospice as one of the ways to manage costs and improve outcomes."

Lessons and advice
 

As HCR ManorCare integrates with ProMedica, social determinants of health are looming large, Cavanaugh says.

"One of the things that has been really eye-opening for us in home health and hospice is that ProMedica has done a lot of good work on being a leader in social determinants of health. They do screenings and put active interventions in place," he says.

"We need to implement both a clinical plan of care and address social issues that get in the way of people getting healthy and staying healthy. We have to find ways to make that work—it can't always be us alone because we have to partner with others in the community and find the right resources," Cavanaugh says.

For health systems that are considering establishing a home health division, Pritts says regulatory considerations related to the Centers for Medicare & Medicaid Services are prominent.

"Medicare is looking at new ways to stratify which patients we see and how often we see them. You need to have a clinical person in place to keep you compliant with all of the changes CMS is making for home health," he says.