In collaborating with hospitals to reduce preventable readmissions, home care agencies that embrace a social work approach stand to be the most valuable partners, according to experts who recently addressed providers in Chicago.
Since the advent of the Affordable Care Act, hospitals have been placing more emphasis on tracking readmissions, especially now that they are facing the third year in which they might be penalized for higher-than-expected rates of patients returning within 30 days.
“Hospitals historically left people to their own devices when they were discharged,” said Laura DeBruin, president and chief operating officer at LifeStyle Options, Inc., a private duty home care services company in Schaumburg, Illinois—located less than 30 miles from where the American Society on Aging’s annual conference was held last week.
“Finally, hospitals are realizing that health care doesn’t stop at their doors and that we all need to work together post-discharge,” DeBruin said.
Working together, however, requires the collaboration of an interdisciplinary team comprising not only primary care physicians and home care staff, but also the key players who facilitate the transition from hospital to home, including discharge planners, pharmacies, and transportation services among other community-based organizations.
Currently, one out of every five (20%) Medicare clients is readmitted to the hospital within 30 days of discharge for the same condition that had sent them there in the first place, according to data from the Centers for Medicare & Medicaid Services (CMS).
Other studies indicate similar results.
Citing a recent analysis from the National Institutes of Health on emergency room readmissions, DeBruin indicated that 23% of patients return to the ER within 30 days after being discharged. Of that proportion, 21-22% return to the hospital.
“Emergency rooms can be good predictors of readmissions,” said DeBruin, who noted that LifeStyle Options is working with an ER discharge planner as one facet of its holistic approach to transitional care planning and reducing readmissions.
The other facets, however, extend beyond basic caregiving in the home.
Piloting success
For LifeStyle Options, transitional care planning begins with an initial assessment and continues well after a patient is discharged from the hospital and begins to ease back into his or her own home, said DeBruin, who has a Master of Social Work degree.
When LifeStyle Options embarked on a preliminary transitional care program pilot in 2012, the company received 23 patients over age 62 who had been to the hospital three or more times for pneumonia in the past few years.
The initial assessment of the client group revealed a number of issues, including medication mismanagement; lack of follow-up with primary care physicians; complications related to discharge diagnoses; and patients’ general non-compliance with their care/discharge plans.
LifeStyle Options also found that many of these patients didn’t know how to get home from the hospital. So the company hired a caregiver who would essentially stay in the hospital with patients, transport them home after discharge and help settle them into their environment.
Continuing to transport and accompany patients to medical and rehabilitation sessions helped eliminate the possibility of missed appointments, which contributes to 20% of hospitalizations, DeBruin said.
A win-win
As part of the assessments within its transitional care program, LifeStyle Options conducts a home safety assessment, which includes not only scoping out potential fall risks around a client’s residence, but also checking the food supply to ensure the patient can remain compliant with dietary care planning.
“Sometimes all it can take is a grab bar in the bathroom to help keep someone from falling,” DeBruin said.
The company also monitors and records vitals, immediately notifying primary care physicians of changes or concerns regarding a patient’s health condition.
If a client lives alone, LifeStyle Option’s program takes cues from the social work field, focusing on creating support systems for the individual, whether it’s coordinating delivery of groceries using Peapod, or the coordination of other outpatient services including home health, access to durable medical equipment, rehabilitation or transportation to doctor’s appointments.
“Our goal was to improve client compliance,” DeBruin said. “When you have a caregiver there it doesn’t mean [clients] will always be compliant. It’s about building relationships, effectively communicating and assisting with the appropriate transitions of care.”
In a more recent study LifeStyle Options conducted, after implementing transitional care planning, the agency was able to keep about 82% of a targeted group of patients out of the hospital in the first 30 days after discharge.
“We found that a little bit of intervention went a long way,” DeBruin said. “Now that we have the data and can bring it to [hospitals], it’s a win-win.”
Written by Jason Oliva
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