Hospital Care Collaboration Extends Reach of Home Health

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)
Hospital Care Collaboration Extends Reach of Home Health

If you subscribe to the McKesson Homecare™ & McKesson Hospice™ LinkedIn page, you may have seen our link to an article describing the care collaboration agreement between Mercy and Senior Independence of Greater Toledo.

This article serves as a powerful example of how home health agencies can extend the reach of hospital systems into patient homes – either after discharge or before an emerging or chronic conditions leads to a hospital admission or readmission.

The agreement “seeks to increase the overall well-being of the patients through education and management of chronic diseases; reduce avoidable hospitalizations, hospital readmissions and emergency department visits; and decrease the overall costs of medical care,” according to a news release about the collaboration.

Mercy serves a 20-county area of northwest Ohio and southeast Michigan with seven hospitals, an area that overlaps much of the service area for Senior Independence (SI).

A key feature of the collaboration will be SI’s implementation of the Home to Stay Program, which helps recently discharged patients manage their chronic diseases to reduce the readmission rate at no cost to the patient.

The release describes the partnership like this: “When a patient is well enough for discharge, a Home to Stay team goes into action. If the team determines the patient requires skilled home healthcare, a SI home-health nurse visits the home within 24 hours and SI provides ongoing care. If the patient does not require skilled home healthcare, a Home to Stay nurse visits the person at his or her home within the next 72 hours and again seven to 10 days after discharge.” In-home visits are followed by phone calls from either a nurse or social worker for 21 additional days.

Specific services provided by SI include:

  • Medication review
  • Vital sign monitoring
  • Confirmation of follow-up appointments and prescribed tests
  • Education about personal health record use such as Mercy’s My Chart
  • Education about disease signs and symptoms
  • Personal emergency planning

Do any of those services sound familiar? Of course they do, because your clinicians likely are performing these tasks during assessment and initial treatment. Clinical and financial executives at leading agencies always are looking for ways to extend the reach of their organizations. What is your organization doing to extend its reach?

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