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Reducing Rehospitalization Rates National average of home care patients who are admitted to the hospital is now 29%, 

Meaning more than 1 out of every 4 home care episodes ends in a hospitalization

Approximately 80 % of patients utilizing the services of Horizon Homecare successfully remain in their home throughout their episode of care (60 days) 

Horizon Homecare average rehospitalization rate for the previous 2 years has ranged from 19% to 21%.

This is 10% lower than the national average

Percentage of Readmissions during an Episode of Home Health Care Lower percentages are better

Horizon Average 19% Percentage of Readmissions during an Episode of Home Health Care

State Average 26%

National Average 29% 0








Improving the Care Transition from Hospital to Home At the community based level – we are embracing the “Institute for Healthcare Improvement How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations

1. IHI recommends the creation of a team to improve care processes between the agency and hospital.  Hernando County Readmission Council – Established  Geratric Medical Associates – Administrator, Physicians, ARNP’s, PA’s  Representatives from home health care: Horizon HomeCare – Owners, Clinical Directors, QA Nurse, Intake, Marketing, Clinicians Baycare – Marketing

Representative hospital staff : Director of Case Management, Quality Nurse, Cardiac Case Manager, Hospitalist,

Skilled Facilities Representatives: Evergreen Woods – Administrator, Director of Nursing, Admissions Director, Social Services Heartland – Administrator, Director of Nursing

Assisted Living Facility: Residence of Timber Pines

Pharmacy: PineBrook Pharmacy –

Key Changes to Improve the Patient’s Transition from a Hospital or Post-Acute Care Facility to a Home Health Care Agency 1. Meet the Patient, Family Caregiver(s), and Inpatient Caregiver(s) in the Hospital and Review the Transition Plan A. Horizon HomeCare offers onsite assessment of patient’s referred to home health, 7 days a week. Our liaison meets the patient, family caregivers, and discharge case manager in the hospital and reviews the transition plan from hospital to home.

1. 2. 3. 4. 5. 6.

Intake to Process referral at facility  Chart review to include diagnosis, history, current lab results and pertinent orders including discharge Medication Reconciliation  Identify family/caregivers in predicting/evaluating home needs of the patient  Conduct a Risk for Hospitalization assessment on all patients beginning at the Intake level: Sample assessment tools that may be utilized

Is the patient 80 or older? Does the patient have moderate to severe functional deficits? a Does the patient have a history of mental/emotional illness? b Does the patient have 3 or more active, co-existing health conditions? c Is the patient taking 5 or more prescribed medications? Has the patient had one or more hospitalizations within the past 6 months? 7. Has the patient experienced an emergency room visit or hospitalization In the past 30 days? 8. Does the patient have an inadequate support system? d 9. Does the patient have a “fair” or “poor” self-rating of health? e 10. Does the patient have a documented history of non-adherence to the







therapeutic regimen? (i.e., drug therapy, diet, etc.)  A patient with a “yes” on 2 or more of these items is judged to be at risk of hospitalization 

a - needs human assistance for at least one basic activity of daily living (bathing, toileting, dressing, grooming, feeding)  b - history of dementia (Alzheimer’s or other) or depression  c - active medical conditions (e.g., diabetes, COPD, arthritis, Parkinson’s)  d - lack of caregivers for critical needs (e.g., ADL assistance, shopping, meal preparation, medication reminders)  e - rated on the question: “Overall, how would you rate your current health?” (Very Good, Good, Fair, Poor) IHI assessment tool High Risk Patient has been admitted to the hospital two or more times in the past year. Patient is unable to Teach Back or the patient or family caregiver has a low degreeof confidence to carry out self-care at home.

Moderate Risk Patient has been admitted to the hospital once in the past year. Based on Teach Back results, patient or family caregiver has moderate degree of confidence to carry out care at home.

Low Risk Patient has had no other hospital admissions in the past year. Patient or family caregiver has high degree of confidence and can Teach Back how to carry out selfcare at home. 

Interventions by Home Health:

Interventions by Home Health

Interventions by Home Health

Prior to discharge: Schedule a follow-up phone call within 48 hours of discharge and schedule a physician office within 5 to 7 days after discharge. Consult with the patient’s physician to identify whether a home health care visit is needed. Initiate a referral to social services and community resources as needed

Prior to discharge: Schedule a physician office visit as ordered by the attending physician. Ensure the patient and family have the phone number for whom to contact with questions and concerns. Initiate a referral to social services and community resources as needed

Prior to discharge: Schedule a face-to-face follow-up visit within 48 hours of discharge. Care teams should assess whether a physician office visit or home health care visit is the best option for the patient. If a home health care visit is scheduled in the first 48 hours, a physician office visit must also be scheduled within the first 3 to 5 days after discharge. Initiate intensive care management programs as indicated. Initiate a referral to social services and community resources as needed 

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Schedule Same Day Admit if patient considered High Risk for Readmission

B. the Intake Coordinator Reinforces to patient, family caregiver(s), and inpatient caregiver(s) the importance of scheduling a follow-up appointment before hospital discharge . Admitting clinician follows through to ensure compliance. Ensure each patient has a primary care physician who will be handling their care going forward and that a follow up visit is scheduled within 2 weeks of acute care discharge  Oak Hill Hospital QA studies have identified post discharge day #10 as high risk for readmission for cardiac surgical discharges.  Contributing factors that we have identified may include: 1. cardiac surgeon discharge frequency for home health of “SN daily x 7 days” 2. Medication Management issues 3. No timely follow up appointment with MD- consider utilizing home visit program through GMA if patient unable to see PCP or surgeon within 2 weeks. 4. Poor communication between home care agency and physician  Interventions: Meeting was held with Karen Dixon, PA on cardiac surgical floor. These issues were brought to her attention. Karen has stopped writing frequency orders upon discharge for these patients. This will allow us to front load visits and to extend care through the critical POD #10 . Specific to patient’s on the 6th floor – Karen has made herself available to clinical staff for questions regarding patient care. Our meeting also prompted an inservice by Karen to several home health providers regarding care of the post cardiac surgery patients.

2. Assess the Patient, Initiate the Plan of Care, and Reinforce Patient Self-Management at First Post-Discharge Home Health Care Visit Horizon is committed to:

Admission of high risk patients within 2-12 hours.

Reconcile all medications (Rx & OTC) within 24 hours of Start of Care.

Provide patients and caregivers with an Action Plan that includes signs and symptoms of deterioration and information about what to do if a situation occurs.

Front load visits/contacts for patients who score at high risk for rehospitalization. Provide additional visits and/or contact for first two weeks of care


Engage, Coordinate, and Communicate with the Entire Clinical Team

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Ongoing team conference via EMR through use of a patient-centered health record to communicate patient information to all caregivers. o Continue Patient Education utilizing easy to understand teach back tools o Reinforce teaching begun in Oak Hill Hospital Weekly onsite team conference with all disciplines Coordination of follow up with PCP or home visit by ARNP or PA if no follow up appointment available with primary MD to ensure early, consistent, real-time consultation as recommended by IHI. Advocate as necessary to ensure referrals are completed and needed services are received.

4. Implementation of Specialty Programs • Cardiac Program

Telehealth Monitoring - CHF

Telehealth Monitoring by a Registered Nurse  Continuity of care by case manager of specialty program  Promotes active patient participation in physician ordered Plan of Care.  Promotes prevention of rehospitalizations with initiation of timely clinical response

 Fall Risk/Balance Program  Wound Management Program  Behavioral Health Program Horizon HomeCare Strategies for Success include: Improving Communication between:

 Hospital and Home Health Agency  Home Health Agency and Patient/Caregivers  Home Health Agency and other Providers Ongoing quality Improvement

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Readmission studies specific to facility Coordination of QA studies with Hospital and Home Health data

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Patient/Caregiver Clinicians Community


Utilizing Technology 

EMR to track unique critical patient data on a daily basis and to allow Real-time interdisciplinary communication

Telehealth to maximize ability to identify potential rehospitalization risk and intervene early


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Small Agency versus large Corporate model allows Immediate Response and Resolution Locally owned, operated and managed by Registered Nurses


Reducing rehospitalizations