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The importance of well-planned healthcare transitions between hospital discharges and home health care helps to avoid re-hospitalizations, especially for those elderly patients with multiple medical conditions. Unplanned readmissions often times indicate a failure in one (or all) of these areas:
In this blog, I will examine some ideas and models that result in more successful transitions of care, specifically between patients returning home after a hospital discharge.
Reducing Problematic Transitions of Care
Experts on the issue of problematic transitions of care report that when patients leave the hospital to receive care in another setting, especially in the home health care setting or nursing home setting, this is when most issues arise. It is critical for the home health agency and the discharging hospital to come together in order to facilitate continuums of care for all of their common patients.
To create an ideal transition to home, the Institute for Healthcare Improvement has recommended the following line items be put into play by the Home Health Agency:
Most Readmissions within Seven Days of Discharge
Most hospital readmissions occur within seven days of discharge. Home health agencies can be utilized by hospitals to avoid some of these recurrences. Ways home health agencies can assist include making certain the patient keeps their physician appointments by helping transport them. So often, missed follow-up appointments can lead to missed opportunities to gauge how effectively the patient understands their post-discharge instructions and to assess patient health.
The Improvement of Care Committee can identify barriers the patient may have in getting to these appointments such as health conditions, and can determine whether a visiting nurse/home visit is more appropriate than is a doctor’s office visit.
If it is deemed most appropriate for a home health visit, this visit should take place no later than 48 hours following discharge, or sooner for those patients at highest risk. Most home health agencies arguably have more time with family members than do hospital caregivers or office nurses—or at least the home setting can be more amenable for families and others to be present—which lends itself to the added benefit of working with family members on a more personal and frequent level.
This can add to the quality of care a patient receives from a home health care agency following hospital discharge since a family member may be more readily present in which to discuss lapses of care or care concerns with the home health nurse—concerns that might otherwise be missed.
Where the Joint Commission Comes In and Helpful Tools Enter
Since 2014, the Joint Commission has been assessing penalties to those hospitals with unusually high readmission rates (re-hospitalizations within 30 days or less, for Medicaid and Medicare patients). Though some believe this is due in part to poverty-stricken regions and patients with few resources, it is worth noting that much of the Joint Commission’s findings have centered on a lack of planning and communication between hospital and home health care providers.
With this in mind, the Joint Commission’s Center for Transforming Healthcare (a 501[c] 3 not-for-profit affiliate) has offered its Targeted Solutions Tool (TST) for Hand-off Communications. The Center describes this as an instrument to provide solutions that have worked during transitions of patient care between an organizational setting to another facility.
While TST is at no cost for Joint Commission-accredited agencies, a tool that is free to all agencies is the SBAR Communication Model.SBAR assists in providing patients and care partners to communicate with other managing clinicians for smoother and more effective continuum of care transitions.
SBAR stands for:
For more information regarding this care model, you may visit the following links: