To Thrive, Home Care Agencies Must Understand the Needs of Hospitals

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

Home Care Agencies Must Understand Hospital NeedsLeaders of home health and hospice agencies certainly understand the important role they play in the continuum of care. But they also must be able to articulate that role to care and referral partners, offering fresh alternatives to help partners tackle their biggest challenges.

“How much time do we spend understanding what the hospital needs?” asks Carol Quiring, president and CEO at Saint Luke’s Health System Home Care and Hospice in Kansas City, Mo. “Our future lies in unlocking the door to acute care.”

The Center for Healthcare Quality and Payment Reform notes that the largest volume of hospital readmissions occurs among patients with chronic conditions, which often reflects inadequate primary care support rather than failings in the hospital setting. But still, hospitals can be penalized. That’s why Quiring suggests that agencies fully utilize the talents of staff to develop a specialty in chronic conditions.

Suggestions include:

  • Diabetic educators
  • Wound, ostomy and continence nurses (WOCNs)
  • Nurse practitioners
  • Cardiopulmonary-certified physical therapists
  • Lymphedema-certified therapists

Quiring’s agency, which serves all or parts of 29 counties in Kansas and Missouri, piloted Internal Case Management, with an RN managing 60-70 patients at high risk for readmission. Quiring says the pilot was shown to cut high-risk readmissions by 7%.

The LACE evaluation tool – an assessment tool that calculates a readmission risk score based on length of stay, acute admission through the emergency department (ED), comorbidities and emergency department visits in the past six months – was used as a patient neared discharge to determine readmission risk. Patient visits began in the hospital, collaborating with a field nurse to develop a plan of care. Patients received telephone calls between field visits as care collaboration continued. After a patient was discharged, a post-episode telephone call assessed patient satisfaction and ability to maintain or improve health.

Quiring says that one secret to successful transitions is a thorough understanding of a patient’s goals, which will be unique to that patient. A way to get at that is through motivational interviewing, which is a collaborative approach designed to strengthen motivation for change. The best evidence in the world won’t be enough to get a reluctant patient to change his ways, Quiring says.

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