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New Model for Hospital to Home Health Care Transitions Supports Readmission Reduction Efforts

January 13, 2014
Contact: Emily White

New Model for Hospital to Home Health Care Transitions Supports Readmission Reduction Efforts

Innovative model and tools look to ease patient transitions from hospital to home health with emphasis on improved clinical outcomes

The Alliance for Home Health Quality and Innovation (the Alliance) - a nonprofit, national consortium of home health care providers and organizations - today released a new resource titled, “Improving Care Transitions Between Hospital and Home Health Care: A Home Health Model for Care Transitions,” comprised of a model and tools for public use. The model and toolkit lay out in great detail an evidence-based approach to successfully complete the transition from hospital to home health care and prevent unnecessary rehospitalization.

The Alliance created this resource through its Care Transitions Technical Advisory Panel and Quality and Innovation Work Group, which consists of clinical experts and leaders in the home health community. Through a literature review and the panel’s collective expertise, the model of care transitions is recommended to facilitate improvements in quality of care. The model is designed for use by home health providers and hospitals, but is available for public use.

As the national debt and health care reform continue to take the policy spotlight, hospitals and other health care providers are increasingly focused on cost saving measures and making an efficient use of health care dollars. Post-acute and rehabilitative care is an example where cost-effective care does not have to come at the expense of patient care and comfort.

“The development of this model and toolkit stemmed from the need for a comprehensive home health-specific model on the necessary steps to improve patient experience and health outcomes during the sensitive transition period from hospital to home health,” stated Teresa Lee, Executive Director of the Alliance. “Our hope is that this new model will aid home health providers in ongoing efforts to reduce avoidable readmissions and in providing quality skilled care in the home.”

Gleaning from other transitional care models and tools, the Alliance identified five key elements that illustrate best practices of transitional care. They include a patient-centered focus, medication management, communication and care coordination, timely follow-up by the health care team and patient-activated education and coaching. Together, these five elements create the foundation for the Alliance’s model of care transitions workflow.

The workflow was developed with two goals in mind: to achieve high patient satisfaction and reduce avoidable rehospitalizations following an acute care hospital stay. Focusing on the 60-day home health episode, the workflow outlines clinical best practices to achieve a successful hospital to home health transition. The workflow supplies home health providers with checklists starting with assessing the patient in the hospital before discharge through numerous subsequent visits. In addition to checklists to guide the transition, the Alliance provides tools to aid clinicians in completing the checklists.

“As the field of home health care continues to advance, the Alliance will continue to refine and develop this model,” added Lee. “We also look forward to collaborating with other leading home health care organizations, including the Visiting Nurse Associations of America and their Blueprint for Excellence Plan, the Home Health Quality Improvement Campaign and the National Association for Home Care and Hospice, all of whom have done great work to support care transitions.”

A leading 501(c)(3) organization in research and education, the Alliance strives to foster solutions that will improve health care at home through quality and innovation.