Hospital readmissions are costly medical events for your clients. Use these tips to train your caregivers on how to prevent readmissions.  

When I was a new caregiver, I worked with a client whom I’ll never forget. Because I was “green,” she canceled her once-a-week visit with me a few weeks during October.

By the end of the month, she decided to give me a shot. I quickly discovered that ambulation was going to be difficult. Her living room couch was covering a portion of her doorway; I moved it back so that she would have more room. Even then, her hallway was too narrow for her walker.  

She lifted her walker up sideways to get through. I insisted that she leave her walker in her bedroom so that she could get back into the living room. She let me hold her arms and assist her through the hallway until she got settled in her chair. Then I brought her walker through.  

I reported to the office that her walker was unable to fit through her doorway, causing her mobility problems and putting her at risk for falling. I didn’t think about it until a few weeks later. I heard that she fell, went back to the hospital, and was discharged to in-patient hospice care. She died a few days later.  

Preventing hospital readmissions should be a top priority for your agency. Some of the reasons include: 

  • Preventing readmission is a key metric for measuring the quality of care being provided

  • Families and clients enlist home care to avoid a trip to  the hospital  

  • Proving that you can reduce readmissions is the key to successful and meaningful referral partner relationships  

In order to measure readmissions, we need to establish a clear definition. The Centers for Medicare and Medicaid Services (CMS) defines hospital readmission as an unplanned visit to a hospital or acute care center within 30 days of discharge from the initial visit – regardless of which institution the patient was admitted to. This doesn’t include planned visits.

Remember, this doesn’t include planned visits to the hospital. And the definition doesn’t specify a reason for the admission, meaning that it can be for the same or a different reason as the original hospital visit. 

Is your agency keeping track of your readmission rates? Make sure to document dates of admission/discharge and any subsequent visits. It may help to notate if they are planned (scheduled ahead of time or anticipated) or unplanned. 

Preventing readmission is a key metric for measuring the quality of care being provided.  

Did you know that readmissions cost Medicare $26 billion dollars each year, $17 billion of which is preventable? Your organization can reduce Medicare spending while keeping seniors safe at home.  

There are many daily life factors that affect readmissions and home care is the ideal source of support to prevent them from happening. According to research from the University of Pennsylvania, there are many social factors involved with individuals who are at high risk for readmission, including their: 

  • Housing situation 

  • Depression and feelings of isolation 

  • Drug or prescription abuse 

  • Poor perceived (and received) social support 

All of these factors can be assessed at home by your caregivers with proper instruction and training. 

Hospitalizations cause a lot of change in your daily operations, including: 

  • Care is put on hold or canceled altogether 

  • You’re not sure when they’re discharging or if they’ll be transferred to a rehab 

  • You retain caregivers, you must move them to other cases 

  • Nosocomial infections (hospital-acquired infections): An example would be if your client gets admitted with abdominal issues they may discharge with other issues.

Home health agencies are well-acquainted with measuring readmissions and tying quality of care to payment incentives. Despite these advancements, home care agencies are not yet subject to their models of payment nor are they required to keep track of those measurements.  

Home care agencies are not yet subject to the value-based purchasing model. But this is a chance to master preventing readmissions to retain clients, retain revenue, and retain caregivers.  

Bearing this in mind, it’s important to keep clients safe and healthy and provide better quality client care regardless of reimbursement model changes.  

One way you could keep readmissions top of mind is by adding a fall prevention or readmission protection task on your care plans for each of your clients. It can serve as a daily reminder for your caregivers.  

Have them look for potential readmission causes like tripping hazards, missed medications, depression, or skipped medical appointments. 

Families and clients enlist home care to avoid going to the hospital.  

Many family members begin their search for home care frantically trying to find a solution for a same-day discharge. They might not have time to shop around.  

Families and clients turn to your agency for help for a variety of reasons. One of these being that they can’t always be there with their family to protect them all the time. When clients are hospitalized, their family and loved ones might not be able to visit them either.  

According to the Home Care Benchmarking Study, hospital discharge planners funneled many of their patients into home care in 2020. Although you couldn’t prevent those clients from their initial hospitalization, you can make it a mission to keep everyone in your care protected from readmission.   

Your caregivers are the eyes and ears for families too. They need to know what to look for to prevent falls and other risk factors for readmission. According to Becker’s Hospital Review, there are certain conditions that make clients more susceptible to readmission, including:  

  • Heart failure

  • Acute Myocardial Infarction (heart attack) 

  • Pneumonia

By paying an extra layer of attention to clients living with and discharged from hospitals with these conditions, you can lower readmission rates.  

When families are notified of a medical event that occurs while caregivers are tending to their loved ones, it can damage your reputation and trust as a provider. 

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“Nobody else in our area is doing this,” says the owner. “When we meet with a referral source, we don’t even have to talk about our services anymore.”

Conversely, when you have a proven track record of readmission prevention – this will help families have peace of mind when they select your home care agency.  

Preventing readmission adds value to care. When you are explaining your billing rates to families, communicate value in the services that you provide. For example, the cost for an average hospitalization for COVID-19 care for the 60+ age group is $77,323. According to the Home Care Benchmarking Study, the range of billing rates for 3–5 hour long visits is $23-32.50 per hour, depending on the geographic region.  

Use these cost comparisons to convey value in the services that you can provide by preventing readmissions while providing quality non-medical care to clients. This can help clients and their payers justify the need for home care services, because of the necessity to prevent hospitalization and readmission.  

Proving that you can reduce and prevent readmission rates is the key to successful and meaningful referral partner relationships.  

Due to the high competition in home care, developing meaningful relationships with referral sources is vital. What are you doing to set yourself apart from your competitors? 

By demonstrating a history of readmission prevention, you have a reason to have more frequent touchpoints with your referral sources. Seize the opportunity to ask if they have any upcoming discharges who may be at risk of readmission.  

It’s easy to say that your home care agency prevents readmissions with the statistics that home care reduces readmission by 25%. Having the receipts to prove it can give referral sources a concrete reason to choose to partner with your agency 

Prepare case studies and use survey data to back your claims. For example, let’s say you haven’t had any readmissions in the last six months. That is a tangible example of your agency’s commitment to providing quality care. Your referral partners will revere your agency as a go-to for referrals.  

They may even have additional tips or recommendations on how to prevent readmissions. Your referral partners could organize a panel discussion or a webinar on the importance of keeping clients at home by preventing hospital readmissions.  

Leverage your readmission rates to anyone willing to listen; your agency will be the go-to for all your referral partners.  

Not every hospitalization is preventable, but they are all an opportunity for learning.  

Your caregivers may not be with a client when a major medical event happens, but your agency can learn from each one.  

Ask the family for details and see if there is anything that can be done to prevent it from happening again. Is there anything that was missed during visits with the client?  

If your client is in the hospital, facilitate the ideal discharge by having everything in place. By staying on top of communication with the family and discharge planners, you can coordinate staffing arrangements and additional training as needed.  

Use the opportunity to reassure families that their loved one is in good hands. Ease their worries since managing a hospital stay is stressful enough.  

Create a plan of action to seamlessly transition them home – and a foolproof plan to keep them there.  

Readmission prevention specialist caregiver training 

Your caregivers play a fundamental role in preventing readmission for clients. You can implement Home Care Pulse training, including our nurse-created specialty learning path to decrease readmission rates in your clients. Some of the topics include:  

  • Understanding Pneumonia: Pneumonia is a common diagnosis for readmission, and your caregivers will learn the causes, symptoms, and treatments for it.  

  • Understanding CHF (Chronic Heart Failure): Heart failure is another common diagnosis for readmission, and your caregivers will learn the signs and symptoms, and how to keep them at home.  

  • Understanding COPD (Chronic Obstructive Pulmonary Disease): COPD makes it difficult for clients to breathe, and your caregivers will learn about what treatments are available to give them respiratory relief.  

  • Reducing & Preventing Readmissions to the Hospital: Your caregivers will learn what to look out for in clients’ homes and in their appearance. They will have the knowledge and skills to detect and prevent those who are at risk for readmission.  

This course offering is a customized curriculum, and at the end of it, each caregiver will become a readmission prevention specialist.  

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If you have a caregiver mentoring program, mentors can lead the way for readmission prevention and foster these principles with their peers.  

Preventing readmissions should be a top priority for your staff.  

Jim Rohn once said, “The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sails.”  

As a leader, it can be easy to get stuck in a flow of negativity and become too familiar with client falls, hospitalizations, and relocation to institutional care services. However, prioritizing readmissions and creating a plan can actively lower hospital readmission rates.   

We can’t expect clients to avoid readmission on their own. Your caregivers and office team are brought in to support a client’s ability to age in place—safely and independently.   

If you can lead by example, and keep client safety and health top of mind, your caregivers and staff will follow suit. They will demonstrate the same commitment in their daily tasks. Giving your staff the tools and knowledge to keep clients out of the hospital will help reinforce your clients’ choice to pick your agency over others.  

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