Link Found Between Amount of Informal Care, Readmission Risk

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)

Increased Informal Home Health Care Reduces Readmission RiskNearly one in five Medicare patients returns to the hospital within 30 days of discharge, which cost the federal government $17.5 billion in 2010. We believe, of course, that home health has a valuable role to play in preventing readmissions.

A new study underlines the importance of a patient’s social factors in determining readmissions. Those factors include:

  • Whether the patient lives alone or with others
  • Whether patient has a primary informal caregiver
  • The type or frequency of informal care given
  • Patients’ age, obesity and level of cognitive functioning

The study, “The Influence of Social Environmental Factors on Rehospitalization Among Patients Receiving Home Health Care Services,” was published in the October/December issue of Advances in Nursing Society. Not surprisingly, patients with the least amount of informal help at home were more likely to wind back up in the hospital after discharge than patients with more solid support systems.

Using data from Medicare OASIS forms, the authors looked at 1,268 elderly patients who were receiving home healthcare. More than one in five patients were rehospitalized, most within the first 20 days after being discharged from the hospital to the home with home health support. Overall hospital readmissions for patients receiving home healthcare have been relatively unchanged since 2004, at about 28 percent.

With hospitals now paying penalties for avoidable readmissions, home health agencies must take a fresh look at how they are helping clients stay healthy in their own homes.

“A transition model between hospital and home health care should include consideration of more social environmental support,” the study authors conclude.

How closely are you monitoring the informal care your patients receive? Are your clinicians the only thing standing between a patient and a readmission?

This presents an opportunity to examine your agency’s documentation and the care your clinicians and aides deliver. As hospitals face higher penalties for a wider array of avoidable readmissions, this is not an issue that will be going away anytime soon.

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