Why Your Home Care Agency Needs to Track Hospital Readmission Rates in 2021

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Agencies that take a data-driven approach to reducing readmissions will not only be able to improve the quality care their patients receive but will add immense value to other partners across the care continuum.

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As healthcare continues to become one continuum of care, home care takes its stance as an essential component of that continuum. Home care services help seniors with basic needs that can be cared for without medical-based services. The senior population wants to age at home and home care provides the opportunity for seniors with low-risk non-medical needs to do so.

As the demand for senior care increases nationwide, agencies are looking to several different channels to find new clients. In 2018, 55% of home care patients came from community settings, 28% came from short-stay hospitals and nearly 12% came from skilled nursing facilities. With each channel there comes unique processes to onboard, understand, care and nurture each client.

Seeing that nearly one in three clients is coming from a hospital or medical channel, home care agencies are faced with an incredible opportunity, but one that has a more complex agenda. Taking on a client that comes from a hospital or medical-based facility means that home care agencies need to assess the client and track their progress and improvement more thoroughly.

One of the most critical ways that home care agencies can add value to the rest of the care continuum is by reducing the number of clients that are readmitted to hospitals. Home care is an ideal setting to focus on reducing readmissions because of its ability to proactively address factors across all parts of a senior’s life that could lead to an issue requiring readmission. Agencies that take a data-driven approach to reducing readmissions will not only be able to improve the quality care their patients receive but will be able to add immense value to other partners across the care continuum, who are increasingly looking for evidence of health outcomes in new partners.

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Top Four Reasons Why Your Agency Should Track Readmission Rates

There are four main reasons why home care agency owners should track readmission rates. Here’s how and why they matter.

1. Improve client outcomes – First and foremost, tracking readmissions puts your agency in a stronger position to reduce the number of clients experiencing episodes or problems that require readmission to a hospital. For the client, this translates to better quality of life, lower costs, and increased health.

2. Qualification for Medicare Advantage clients – Insurance agencies that have clients that qualify for Medicare Advantage are looking to pass their clients on to home care agencies that will reduce their clients’ chances of being readmitted into a hospital. Home care agencies that can prove their reduced readmission rates will obtain more of these clients. Moving into 2021 obtaining these Medicare Advantage referrals will in large determine the success of home care agencies.

3. Credibility as an agency – As your agency reaches out to the many channels for more client referrals, whatever data you can leverage will work to your advantage. Professional referral sources want to see your credibility backed by data. If you can accurately track reduced readmission rates internally, you’ll let referral sources now you’re making it a priority and you’re more likely to be trusted with their clients.

4. More referrals from medical service providers (hospitals, clinics, SNFs, etc.) – More than any other channel hospitals want to see your agency is reducing readmission rates because they benefit from keeping their patients from coming back to the hospital. If you can show a hospital you’re tracking and reducing readmissions, they’re likely to trust you over your competitors and pass more referrals to you.

According to a brochure created by Right at Home, 1 in 5 patients will be readmitted to a hospital within 30 days. And according to Guy Tommasi, a successful home care agency owner and board member of the Connecticut Association for Healthcare at Home, “One key driver behind the hospital readmission revolving door is a lack of coordination of care after discharge.” Facilitating client communication and coordination should be an agency owners’ bread and butter to obtain more client referrals from hospitals and other professional medical clinics.

As competition in the industry continues to increase, it’s not enough to just believe your agency is reducing readmissions. You must back your claims with data. Readmission rate data can serve your agency as a basis to execute the three main reasons outlined above.

Basic Framework to Begin Tracking Readmission Rates

  • Begin tracking readmission rates – most scheduling software include a system or setting to track readmission or custom fields that would allow you to do so.

  • Develop a care plan that specifically takes into account that client’s risk of re-hospitalization and focuses on minimizing the factors that could cause it.

  • Track when the client was admitted to medical care and when the client was discharged and why. Also take note if the client improved and no longer needed care, or if the client went back to the hospital. Track these percentages internally as an internal benchmark that can be measured each quarter or year over year.

  • As a part of your assessment, build in routine wellness checks, doctor’s appointments or medication reminders.

  • Make training your caregivers on basic medications, avoiding falls, and basic home safety a priority. In 2019, only 13.1% of home care agency owners reported ‘preventing readmissions’ as a caregiver training priority. 

  • Track common trends and conditions that you see with your clients to use as data that can help you improve your process and reduce readmissions moving forward.

As healthcare and home health continue to tighten the reins on regulations and qualifications, home care providers should take note and follow suite. Although the level and complexity of care varies between services and providers at each phase of the continuum, home care agency owners have the responsibility to maintain a high standard. Tracking readmission rates is a good way for home care agencies to improve their contribution and add value to the continuum of care.

Tactics to Help Your Agency Reduce Readmissions:

  • Know which of your clients are at risk for readmission

  • Ensure your staff is aware of your high-risk clients 

  • Train your caregivers on basic medications and dosages

  • Specialize in care for specific conditions or diagnoses

  • Train caregivers to help your clients avoid falls (in-home safety)

  • Ensure that high-risk clients are routinely meeting with their doctor or physician as necessary

  • Encourage prompt prescription pick-up for clients

If these steps sound simple, it’s because they are. However, while many agencies are already taking these steps, few of them are taking these steps as a part of a cohesive plan with reduced readmissions as its North Star. Without a clear, unifying goal, these efforts are unlikely to produce a meaningful reduction in readmissions.

Reducing Readmissions Can Result in More Referrals in 2021

As part of the continuum of care, home care plays a large role in allowing seniors to age at home instead of inside hospitals and medical facilities. It’s very common for a senior who has had health problems in the past to experience minor accidents or issues that put them back in the hospital. Non-medical home care is ideal to help with this because so many strategies to reduce readmissions require proactive efforts in the senior’s daily life.

More and more professional referral sources will begin to seek out home care agencies that reduce readmissions and if your agency is one of them, 2021 might be your best year yet.

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