How 2 Home Health Providers Fine-tuned Hospital To Home Transitions

Home-based care providers are often uniquely positioned to play a critical role in timely hospital to home transitions. Organizations like Care Central VNA & Hospice and Choice Health at Home have made ensuring smooth transitions a major priority.

At the start of the transition process the first 48 hours are especially important, according to Holly Chaffee, president and CEO of Care Central VNA & Hospice.

“We always see our patients within 48 hours of release from the hospital,” she told Home Health Care News. “What it entails is making sure that we get the appropriate paperwork from the hospital, which would include a discharge summary, a face-to-face document and an accurate med list for what the patient is taking in the hospital, so that we can do the med reconciliation when they arrive home. One of our biggest challenges is getting all those documents from the different hospitals.”

Webster, Massachusetts-based Care Central VNA & Hospice has been in business for over 100 years. The company serves five counties and 98 towns in Massachusetts. It offers home health, hospice, private-duty care, adult day care and a healthy families program.

Gathering the appropriate paperwork can sometimes be a pain point for home-based care providers depending on the hospital or health system.

“If we have access to the hospital medical record … we have less difficulty in obtaining the paperwork,” Chaffee said. “Some of the hospital systems don’t allow access to their patients’ records that we serve, and that makes it a bit of a challenge. That’s likely because there are so many different variations of medical records out there. Having the paperwork to give a good picture for the clinician who’s going to be visiting is very helpful.”

Indeed, Care Central VNA & Hospice is using AI-software to summarize patients’ hospital records.

At Choice Health at Home, taking on the role of an advocate for patients coming into the home has been key.

“That means if we don’t have all of the information we need to pursue that with the hospital system, via follow up phone calls or working through the portals,” David Jackson, CEO of Choice Health at Home, told Home Health Care News. “It’s also really important for us to advocate for the patient, as soon as we get on site, post-discharge from the hospital. Home health may be just one part of the discharge plan, so it’s really important for us to advocate for the patient, and be a tool for the hospital to ensure that discharge home.”

The Tyler, Texas-based Choice Health at Home is a home health, hospice, palliative care, rehabilitation and home care services provider. It operates locations across Texas, Arizona, Louisiana and Oklahoma.

Speed to care is imperative, and when hospital to home transitions don’t go smoothly it can have an extremely negative impact on patients.

In 2022, researchers noted when post-acute care handoffs weren’t as effective as they should be, patients were more likely to suffer a setback requiring another hospitalization.

On the flip side, it benefits patients when the process happens seamlessly.

“When we help with that transition, and we’re out there quickly and timely, it is less likely that patients have to be readmitted to the emergency room,” Jackson said.

For Care Central VNA & Hospice, staying on top of the hospital to home transition process has helped the organization lower its re-hospitilization rate, Chaffee noted.

Jackson said he believes that the best way for providers to position their organization to excel at the transition process is to have a strong intake team.

“Your intake team — which is really a hybrid between your office staff and your sales team — are the first people to talk to these patients,” he said. “They are also working with the hospital systems. They’re the tip of the spear, so really working to train, motivate and encourage your intake team and talk to them about their role in the mission is important. Best practices start with your intake team.”

Jackson also noted the importance of making sure the intake team has the necessary tools to accomplish timely transitions. This means quality document management software and the ability to automate when appropriate.

Ultimately, strengthening communication and relationship building are the best way to stay ahead.

“You know the people that you’re talking to on the other end of the phone, you build those relationships and there’s a trust that you will follow through with what you say and get that patient seen as soon as possible,” Chaffee said. “I would say communication is the number one issue, whether it’s via email, through portals, through telephone calls or visits to the hospital to see that particular patient. You have to make sure that we have like, all the I’s dotted and T’s crossed.”

The post How 2 Home Health Providers Fine-Tuned Hospital to Home Transitions appeared first on Home Health Care News.