By: Tracey Shoop, Transitional Care Program Director
For those suffering with long term health problems or chronic conditions, going back and forth to the hospital can become a normal routine. Recreating the care from the hospital to the home can become a daunting task. Assisted is proud to offer an Enhanced Home Health program with the primary goal of reducing avoidable readmissions by keeping our patients supported and home through proper care transitions.
#1: Personal Contact and Communication with Patient
After leaving the hospital or skilled facility, our patients will be receiving supportive services from both our nursing field staff as well as from our internal staff. Once the patient is home under the Enhanced Home Health program, they will be receiving post discharge instructions from their nurse, as well as education about their disease. The program offers increased communication with our office staff as well. The goal of reduced readmissions can be achieved in part by, proper care and management of the patient, insuring patient follow up with their primary physician, and medication management.
#2: Increased Coordination of Patient Care
Preparing to discharge from the hospital to home, or a skilled setting requires collaboration from the hospital and its partners. Assisted’s Enhanced Home Health program provides a pre-hospital discharge visit with the patient and family, and offers an opportunity for all to participate in the discharge plan. In order to reduce readmissions and ensure success with patient outcomes, it is important that all understand what is required once the patient is discharged, and how Assisted’s staff will be coordinating their.
#3: Enhanced Home Health Touch Points
Assisted’s Enhanced Home Health program provides a series of touch points that have been proven to reduce hospital readmissions. Under this program patients have had a decrease in readmissions back to the hospital by 32%. The program offers a pre-discharge visit at the hospital from Assisted’s Home health Liaison, Home health nursing visit the following day, Friday afternoon phone calls to the patient for four weeks, and weekend visits the first two weekends the patient is home. Most readmissions to the hospital occur within the first 7-14 days a patient goes home. Offering these services are all ways to avoid unwanted readmissions while also managing chronic diseases, and preventing health emergencies from occurring in the first place.
#4: Financial Penalties
As of October, 2014, our hospitals now face a financial penalty of 3% for Medicare patients that return to the hospital within 30 days for certain disease specific diagnoses. The hospitals now need to look at their community partners in extending the care given within the hospital to home. Assisted’s Enhanced Home Health program implements a proven readmission reduction process by increased support to the patient and family during their transition home.
To reduce your readmissions today or learn more about Assisted’s Enhanced Home Health program call 800-949-8555 or contact your local Assisted branch (click here for locations).
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