By JOHN BANKS POWELL
When patients transition from one care setting to another, there is an increased need for quality care coordination and patient support. Typically, patients will move from a care setting, such as a hospital, that is giving round-the-clock resources to monitor, help and improve a patient's condition to a level of acuity with much fewer resources. This period of time is critical to ensure patients stay on the path to recovery and follow designated care plans.
During a transition, there are other anticipated challenges that providers aim to address in addition to fewer resources. According to the results of the National Adult Literacy Survey (NALS), only 12 percent of U.S. adults have proficient health literacy. Add this to the fact the less than 25 percent of patients report they comprehend the instructions given to them at discharge and it is clear that care transitions can make the difference in positive or negative outcomes and experiences.
Where Home Health Agencies Play a Role in the Care Transition Process
Given how important the transition of care is, it is no surprise to see that home health agencies are becoming an increasingly popular post-acute service. Instead of opting for longer hospital stays or time in a rehab facility, more and more patients are choosing to recover with home health services. Hospitals are also financially incentivized to move patients into lower cost care settings sooner. Nearly five million patients receive home health services in the United States each year, and current estimates show that the home health industry could grow to $350 billion in revenue by 2020. With this volume of activity there are many ways in which home health agencies should take advantage of being able to support better care transitions.
Patients typically receive home healthcare services after they are discharged from a hospital or skilled nursing facility, or can be referred by community physicians. With regular home visits, agencies have the opportunity to check in on patients, ensure they are adhering to care plans, and offer educational resources to help them manage any conditions. While the home visits themselves can directly improve outcomes, there are opportunities to engage patients outside of these face-to-face interactions to further improve both patient outcomes and patient and family experiences.
Patient Engagement Plays a Critical Role in Preventing Potential Issues
Patients receiving home health services are face-to-face with a healthcare professional on a regular basis. Engaging patients beyond these interactions is where home health agencies have the opportunity to further improve outcomes and keep patients satisfied with their care. With telephone outreach, agencies can engage patients in the white space between their home visits and address potential gaps in care plan comprehension or adherence. For example, if a patient receiving home health ha questions about their medication between visits, phone call outreach can engage the patient to understand his or her needs and then connect them with the proper resource to resolve this issue without having to wait until the next home visit. This proactive communication helps address potential care issues before they occur and can improve outcomes such as re-hospitalization or readmission rates.
When it comes to engaging patients throughout their episode of care, there are a few things providers should keep in mind. Although phone or text message outreach can be extremely effective, it is important to make sure the process is both scalable and personalized. Creating scalable processes is critical, not just due to the high volume of patients on census, but because staff turnover is one of the biggest challenges in the home health industry right now. When implementing a patient engagement program, agencies should focus on finding ways of ensuring staff members are working at the top of their license and helping patients more than simply completing administrative tasks like check in calls.
For patients, it also ensures outreach is tailored to their preferred language and communication method such as calls or text messages instead of emails or direct mailings, which is proven to not be as effective in resolving issues in a timely manner. By keeping patient preferences top of mind, there is an increased likelihood of engagement and therefore program success.
Improving Care Transitions Improves Reimbursements Across the Continuum
For hospitals, reimbursements are tied to metrics such as readmission rates and HCAHPS scores. Oftentimes, patients will view home health as an extension of the care they received in the hospital, even if the entities are completely separate. When patients are satisfied with their home health services, this can have a tremendous impact on their view of the hospital care as well. Additionally, if the home health agency can help to prevent avoidable 30-day readmissions, that will directly impact the hospital's reimbursement as well.
Home Health Agencies also have the opportunity to capitalize on changing regulations with proactive patient engagement. In 2020, agencies will shift to reimbursement under the Patient-Driven Grouping Model (PDGM). The major changes with PDGM will be a shift from 60-day to 30-day payment periods, and higher reimbursement for institutional hospital referrals. By improving patient outcomes and their perceptions of care, agencies can showcase their superior quality and increase the volume of referrals from preferred institutions providers, improving their bottom lines.
As health systems and integrated delivery networks seek to improve care transitions, home health agencies that are proactive and innovative in engaging patients can be a tremendous asset. As potential patient issues are prevented, care providers throughout the entire patient journey stand to gain both patient loyalty and financial reimbursements by keeping patients engaged during transitions of care.
John Banks Powell is the Vice President of Post-Acute Strategy at CipherHealth. Powell spearheads CipherHealth's post-acute and bundled payment initiatives by partnering with providers across the care continuum who leverage CipherHealth's patient engagement and care coordination solutions to meet quality initiatives. Visit cipherhealth.com