Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

9781943542147: Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

Timely home visits following patients' discharge from the hospital offer patients tools and support that promote self-management and reduce the likelihood of readmission to the hospital.

In this report, transitional care business manager at the Council on Aging (COA) Southwestern Ohio, describes her organization's home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

Cognizant that poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and the inappropriate use of hospital emergency and post-acute services, COA developed the home visits intervention, in which field coaches conduct post-discharge visits to patients at home and/or within skilled nursing facilities (SNFs). 

Home visits are a key feature of COA's care transition management initiative, modeled on the evidence-based Eric Coleman Care Transitions Intervention ® (CTI)®. With its focus on community support, the COA care transitions program is designed to help patients access the most appropriate post-acute medical care and home community-based services to avoid more costly nursing home placements when unnecessary.

COA is a member of the Southwestern Ohio Community Care Transitions Collaborative, the second program in the nation accepted into CMS's Community-Based Care Transitions Program (CCTP). The goals of the CMS CCTP are to: improve transitions of beneficiaries from the inpatient hospital setting to other care settings; improve quality of care; reduce readmissions for high-risk beneficiaries; and document measurable savings to the Medicare program.

This special report provides the following details:

  • The evolution of the COA care transitions intervention and home visits' critical contribution to this initiative;
  • The essential 5th pillar COA added to the CTI model to improve care transitions;
  • The roles of hospital and field coaches in the care transitions, home visits and SNF interventions;
  • Elements of the home visit and SNF interventions, including medication reconciliation to identify discrepancies, and role-plays to prepare patients for provider questions and concerns;
  • The structure of telephonic follow-up after completion of the home and/or SNF visit;
  • The necessity of data analytics to shape, evaluate and justify a home visit or care transition program;
  • A COA strategy to navigate Medicare reimbursement restrictions and offer some patients a follow-up home visit following their SNF visit;
  • Future plans for tailoring home visits and the SNF experience to the big 5 chronic diseases pneumonia, diabetes, multiple chronic conditions, COPD and CHF as well as behavioral health.

In an expanded Q & A section, a host of details on the tools and hallmarks of the program is provided, including coach skill sets, coping with patient pushback, coach-home visit ratios, and more.

Table of Contents

  • Home Visits: 5 Pillars to Reduce Readmissions and Empower High-Risk Patients
    • Southwest Ohio Care Transitions Collaborative Goals
    • Using the Coleman Care Transitions Intervention (CTI)® Model
    • Hospital and Field Coaches
    • Expanding the 4 Pillars of the Coleman Model
    • Medication Reconciliation During Home Visits
    • Home Visit and SNF Visit Interventions
    • Telephonic Follow-Up
    • Future Plans
  • Q&A: Ask the Experts
      and more...

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