Home Care Heroes Blog

4 Steps for Home Care to Reduce Readmissions

Private Duty Home Care Industry, NPDA and PDHCA Must Measure Home Care's Impact in Reducing Avoidable Readmissions and Actively Promote Results NOW


Unless you just fell off the turnip truck, then you are keenly aware that reducing avoidable hospital readmissions is one of the primary concerns in healthcare today. Hospitals and ACOs face significant CMS penalties for higher rates of readmissions for certain diseases, which became effective last month and will quickly become more severe. Home Care is in a terrific position to be a low cost, highly efficient part of the solution -- but this opportunity will not remain open for long.

The statistics on avoidable readmissions warrant repeating: 

describe the image...All for reasons that CMS, private payors, and most providers acknowledge could have been avoided. Pilot after pilot shows that with planned, effective follow up, readmissions rates can be reduced by a third, a half or even more in some cases. Organizations that have made decisive efforts to provide patients with support and follow up after discharge are realizing these dramatic reductions in their rates of readmissions.

The common theme among them? They have a plan. And they follow it.  Call it the emergence of Accountable Care, call it Care Coordination or even a glorified version of "let's get this patient some help so they are not completely on their own."

Home Care is in a terrific position to fill a valuable role in reducing readmissions and has proven its worth repeatedly. Still, few outside of the home care industry seem to know it. Why is it that this is not being promoted more aggressively?

See related Ankota blog article here: Hospitals Looking to Home Care in Cutting Patient Readmssions

When Ankota is working with hospitals and ACOs we always ask them what types of organizations they envision coordinating within their ecosystem. They rarely mention non-medical home care on their own. Howewever, when we suggest they consider non-medical support services be coordinated in the home, the unanimously agree that home care is a great resource. Out of site out of mind. That's the issue.

Ecosystem: a collaboration of providers that cooperate to Plan, Coordinate and Deliver care. Care is increasingly being delivered outside of traditional hospital settings and requires that numerous providers coordinate in an integrated service model. 

A plan that coordinates both medical and non-medical services to support a patient after discharge has been proven to reduce readmissions, yet the Home Care industry does not do a good job of a) measuring its impact on readmissions and b) promoting itself as integral to the ecosystem that is responsible for successful results.

Even on the National Private Duty Association home page, there is no reference to the success that Home Care agencies are having in helping to reduce readmissions. Further, on the Private Duty Homecare Association web site there is no reference to the industry's role in this.  Neither organization appears to be a) engaging in pilots, b) measuring success, or c) actively promoting the industry to those who are in a position to make decisions that assures Home Care a strategic role. 

There is a limited window in which to act and Home Care is in danger of being left behind. As hospitals and ACOs drive forward, they are increasingly looking to post-acute services to help manage Care Transitions and proactively care for patients in the community. Primary Care Physicians and Home Health Care nursing are obvious partners, yet provide an incomplete picture. A complete ecosystem is required for comprehensive care. Those that provide specialty nursing such as infusion, or provide physical and occupational therapy, or deliver equipment (HME) and medications (pharmacy) are increasingly included. If Home Care waits for the leadership of others to drag them in, it will come too late and will be disintermediated. A progressive approach that initiates and sponsors pilot projects between Home Care and these other participants, guarantees to measure and publish results, and does so with complete professionalism and care will position Home Care as a vital participant in the ecosystem.

Steps that you and the industry must take now

Identify pilot Projects that require collaboration with other types of providers, have clear objectives

Coordinate care & share information with partners

Leverage technology for operational efficiency & care coordination

Measure performance & share results

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Ankota's technology organizes providers into ecosystems to better Plan, Coordinate and Deliver care across the continuum. Ankota's technology coordinates hospitals and ACOs with post acute care, and optimizes post acute operations. Ankota's Private Duty Agency Software is the most comprehensive, easiest to learn and use system on the planet.

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