Patient Transition of Care and Home Health Agencies

May 4, 2021

The importance of a well-planned patient transition of care between hospital discharges and home health care helps 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:

  • Discharge practices or processes of hospitals
    • Poor communication of care plan to home health care team
    • No discharge care plan
    • Referral delay to home health care setting
  • Quality of care in home health care settings (or other community care settings such as doctor’s offices or skilled nursing facilities)
  • Inability of patients to manage their own care, or lack of support
  • Caregivers not addressing whole-patient needs (e.g. underlying issues; mental health diagnoses)

In this blog, I will examine some ideas and models that result in the successful patient transition of care, specifically between patients returning home after a hospital discharge.

Reducing Problematic Transitions of Care

Experts on the issue of problematic patient transition 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:

  • CEO (or equivalent) denotes an Improvement of Care Committee whose charge it is to improve cross-setting care processes for post-discharge patients.
  • Selects a nurse (director of nursing at home health agency, or equivalent) to lead the team in quality improvement processes.
  • Appoint partners in doctors’ offices, hospitals, nursing facilities, board members, and even select patient family members to join the cross-continuum team.
  • Team members analyze referral streams and develop standard referral processes.
  • Recommend opportunities for improvement
  • Explore and develop Web-based referral and accountability mechanisms
  • Develops these policies and procedures and openly shares with front-office staff persons, home health aides, agency nurses and therapists, partner hospitals and other referral agencies.
  • Tests, measures, and tracks progress (or lack thereof) made through the Improvement of Care Committee’s recommendations.
  • Improvement of Care Committee recommends further improvements and revisits policies’ effectiveness within pre-arranged time periods.

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 affiliates) 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 with communication with other managing clinicians for a smoother and more effective continuum of care transitions.

SBAR stands for:


For more information regarding this care model, you may visit here


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