A CMO's Guide to Offering Home Health Services

Offering home health services to patients after hospitalizations generates several benefits, including improved patient satisfaction, reduced readmissions, and lower cost of care.

Health systems and hospitals should offer home health services to their patients internally or with partners to improve clinical outcomes and reduce hospital readmissions.

Offering home health services to patients is part of the ongoing strategic movement to providing care beyond the walls of hospitals. After hospitalizations, the benefits of offering home health services beyond reducing readmissions include increasing patient satisfaction and providing services at a lower cost than services at a skilled nursing facility.

Dartmouth Health provides home health services to patients after hospitalizations in a partnership with Visiting Nurse and Hospice for Vermont and New Hampshire (VNH).

"Home health services are an integral part of healthcare and an increasingly important aspect of how health systems deliver care to their patients," says Edward Merrens, MD, chief clinical officer at Dartmouth Health. "First and foremost, patients want to be home, and increasingly, the therapeutic procedural and interventional care that we provide allows patients to return home for recovery."

In addition to boosting patient satisfaction, offering home health services promotes value-based care, according to Merrens.

"Following therapeutic stays in the hospital, we are focused on how we get patients home versus a discharge to skilled nursing care or swing beds," Merrens says. "This is even more important as we think about our participation in the Centers for Medicare & Medicaid Services TEAM initiative, which looks at the total costs of care and post-hospital care."

In May, Maimonides Health began a partnership with myLaurel, with an emphasis on offering home health services to high-risk patients after a hospital episode of care.

By offering home health services through myLaurel, Maimonides Health is generating benefits for patients and the health system, according to John Marshall, MD, executive vice president and CMO at Maimonides Health.

"When patients are discharged from a hospital to the home, there is a lot of uncertainty," Marshall says. "Patients are worried. They want to know that they are safe. There also is an interest in shortening length of stay in the hospital, and a lot of recovery after a hospitalization happens in the home."

For Maimonides Health patients who have received services from myLaurel, patient satisfaction scores have increased significantly, and preliminary data shows readmission rates have fallen 25%, Marshall says.

Northwell Health offers a range of home health services, including through Northwell Health at Home, which is a fully integrated home health division of the health system. It is a certified home health agency serving several counties and the five boroughs of New York City.

Offering home health services is a prime example of how health systems are redefining hospital-based care, according to Jill Kalman, MD, CMO, executive vice president, and deputy physician-in-chief at Northwell Health.

"While hospital and home services are not novel, our specific offerings can be," Kalman says. "By implementing unique programs, emphasizing the continuum of care from preventative to acute care, and integrating new technologies into everyday care, we can improve both patient outcomes and recovery—far surpassing what a hospital visit alone could achieve."

Edward Merrens, MD, is chief clinical officer at Dartmouth Health. Photo courtesy of Dartmouth Health.

Models of home health services

VNH offers home health services for patients at Dartmouth Health and other healthcare providers in Vermont and New Hampshire. The organization offers several home health services, including nursing care, occupational therapy, physical therapy, and hospice care. For Dartmouth Health patients who choose to receive home health services from VHN, referrals are sent electronically to VHN's electronic medical record.

VNH and Dartmouth Health take a collaborative approach to providing home health services for patients, according to Tammy Tarsa, MBA, BSN, RN, president and CEO of VHN.

"Dartmouth Health and VNH want patients to be healthy and receive great care," Tarsa says. "So, the relationship between the inpatient care team and the home health team is Dartmouth Health provides care in the hospital, and we provide care in the home, and we transition the patient to home health services seamlessly."

An example of strong collaboration between VNH and Dartmouth Health is in the care of complex patients with multiple needs, Tarsa explains.

"The hospital care team can reach out to our team through our patient access manager," Tarsa says. "The hospital care team communicates the needs of the patient, and we often loop in additional community resources for the patient."

VNH home care professionals work with Dartmouth Health clinicians to avoid hospital readmissions.

"We watch the patient in the home, and when we start to see exacerbations of symptoms, we can do something about it," Tarsa says. "We can circle back to the patient's clinician and intervene with measures such as medication adjustments before a patient has to go back to the hospital."

The partnership between myLaurel and Maimonides Health provides patients with an opportunity to transition from the hospital to the home in a way that meets the patients' needs, according to Marshall.

"With myLaurel, we can fill the gap between the hospital and primary care physicians with wraparound services," Marshall says. "The patient gets timely and tailored care that is closely integrated with the care that the patient received in the hospital."

One of the valuable features of myLaurel is provider presence and provider backup, Marshall explains.

"They can get a physician involved in the patient's care to adjust doses of medication or the treatment plan," Marshall says. "This care is provided in conjunction with the hospital care team."

The care team at myLaurel also can connect patients with needed services that may have not been identified at the time of hospital discharge, according to Marshall.

"For example, we may have not identified the need for occupational therapy, and myLaurel can connect the patient with that service," Marshall says.

Northwell Health at Home provides several home health services, including skilled nursing, physical therapy, occupational therapy, and social work.

"Northwell Health at Home also has specialty programs that we have developed in conjunction with our inpatient service lines such as programs for heart failure, stroke, diabetes, wound care, and pneumonia," says Meredith Desimone, MPH, vice president of continuing care at Northwell Health and deputy executive director at Northwell Health at Home.

The referral process for patients at Northwell Health hospitals to Northwell Health at Home is efficient, Desimone explains.

"When a patient is in the hospital, their interdisciplinary care team will identify that the patient has a need or needs in the home after hospitalization, then they make a referral to Northwell Health at Home's referral center," Desimone says.

There is a strong relationship between Northwell Health inpatient care teams and Northwell Health at Home care teams, according to Desimone.

"As part of the health system, we have integration with our Northwell Health hospital teams," Desimone says. "Patient handoffs between the hospitals and our home health teams happen seamlessly, and we have ongoing communication between the hospital care teams and the home health teams."

John Marshall, MD, is executive vice president and CMO at Maimonides Health. Photo courtesy of Maimonides Health.

Jill Kalman, MD, is CMO, executive vice president, and deputy physician-in-chief at Northwell Health. Photo courtesy of Northwell Health.

Tammy Tarsa, MBA, BSN, RN, is president and CEO of Visiting Nurse and Hospice for Vermont and New Hampshire. Photo courtesy of Visiting Nurse and Hospice for Vermont and New Hampshire.