UCLA Health has formed a partnership with three home health agencies that agreed to increase the number of times home health nurses interact with patients after they are discharged from the hospital to home with home health services.
The agencies agreed to provide a minimum of seven “touch points” or contacts with patients during the first two weeks after discharge.
The home health nurses either visit the patients while they are still in the hospital or introduce themselves with a telephone call before the patient is discharged.
They make two to three home visits the first week, including a visit within 24 to 48 hours of discharge and a home visit the first weekend the patient is at home.
The home health agencies agreed to provide two to three home visits the second week, including a home visit the second weekend the patient is at home. They make “tuck in” telephone visits on the first and second Fridays to check on the patient.
“The touchpoints have tremendous benefits for the patients. In addition, the program has greatly improved our relationship with participating home health agencies,” says Marcia Colone, PhD, ACM, LCSW, system director for care coordination at UCLA Health in Los Angeles.
The health system’s first analysis of patients seen by the home health agencies showed no significant difference in readmissions or emergency department visits between the enhanced home health services and standard services, Colone says. However, a second analysis showed that patients who were part of the enhanced home health program were less likely to be readmitted to the hospital than patient who received regular home health services, she adds.
As part of its initiatives to reduce readmissions, UCLA Health created the Enhanced Home Health Quality Council, a partnership between the health system and the home health agencies. The goals of the council are to improve communication between UCLA Health facilities and external providers, to create an infrastructure to allow accountability, and to standardize referral processes as patients move from the inpatient to the outpatient setting.
The council meets regularly to share information and solve problems, Colone says. Among the accomplishments so far are standardizing the discharge process and the discharge information the providers receive, creating an infrastructure to allow accountability, and standardizing the referral process between the inpatient and outpatient settings.
“The home health agencies were very eager to participate in the program and were willing to add additional phone calls and visits to their routine services at no cost to UCLA or the patient,” she says.
UCLA Health has formed a partnership with three home health agencies that agreed to increase the number of times home health nurses interact with patients after they are discharged from the hospital to home with home health services.
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