Reducing hospital readmissions is a challenge that home health agencies face every day. According to the Centers for Medicare and Medicaid Services (CMS), one out of every five patients who are discharged from a hospital is readmitted within 30 days.
The Hospital Readmissions Reduction Program (HRRP) is a Medicare program that financially penalizes hospitals with high readmission rates. The program encourages hospitals to partner with home health agencies and invests in services that reduce readmission rates.
Improving patient experience for a complete transition from the hospital to home health is essential in reducing readmissions and avoiding financial penalties. Here are five proven strategies that can help home health agencies reduce hospital readmissions:
Value-based oncology care requires an effective communication system between hospital staff and home health providers. This communication should include exchanging patients’ medical records, treatment plans, medication regimens, discharge instructions, and follow-up care. Regular meetings between the hospital team and the home health agency ensure that all stakeholders are adequately informed about the patient’s progress.
High-risk patients who leave the hospital can benefit from post-discharge care coordination. A designated coordinator at the hospital should ensure that discharge instructions are clear and up to date, while home health providers should plan follow-up visits within 24 hours of a patient’s return home.
Post-discharge follow-up is essential for reducing readmission rates in home health. It is crucial to provide adequate follow-up care and communication with physicians, family members, and patients following discharge. This helps ensure that the patient’s condition does not deteriorate and increases the chances of successful rehabilitation at home. Home health agencies should track post-discharge follow-up calls and monitor follow-up care plans to keep readmission rates low.
For example, cancer patients are prone to infections, so home health agencies should ensure that follow-up calls are made to detect signs of infection before it can become severe.
Oncology patients, especially, may require home health support to avoid readmission. Evidence suggests that patients with a solid social support system are more likely to follow their care plans and heal better after discharge. Home healthcare professionals can help ensure that patients’ caregivers have the skills, knowledge, and resources needed to provide adequate assistance at home.
These include helping to coordinate access to essential services, such as transportation, nutrition resources, and home modifications.
Effective communication between hospital staff, home health agencies, and patients is essential to reduce readmission rates. In many cases, language barriers can lead to miscommunication, which can be costly in the long run. Home health agencies should partner with organizations that specialize in bridging language gaps and provide access to interpreters when needed. Additionally, hospitals should ensure that patients receive proper discharge education and understand what they should do to stay healthy.
As healthcare becomes more digital, home health agencies can utilize technology solutions such as remote patient monitoring (RPM). RPM in oncology, for example, can provide real-time health data that allows home healthcare providers to monitor patients in the comfort of their homes. Patients can collect information like pulse oximetry, blood pressure, weight, and electrocardiogram data and transmit it to their healthcare team.
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