Toni Cesta, PhD, RN, FAAN
Introduction
Transitioning patients to the next level of care is a fundamental role of the hospital case manager. As a result of reductions in length of stay, penalties for readmissions, accountable care organizations, and Medicare contract auditors, the need to ensure a smooth transition for our patients has never been more important. Therefore, home care has never been more important and has risen to the top as a crucial component of discharge planning in the new health care reform reimbursement system. Home care plays a role in reducing returns to the emergency department and readmissions to the hospital by assisting patients in staying safely in their home environment.
This month, we will talk about your role in identifying patients who may need home health services so that no patients who qualify will be overlooked!
What Is Home Health Care?
Home health care is a medically oriented approach to providing care in the patient¡¦s home. It is different from home care services, which may include chores and housecleaning services provided by home health aides and other non-skilled providers. Home health care may include occupational and physical therapy, speech therapy, and skilled nursing. Patients may receive skilled medical care, home support services, or a combination of both.
A Gap Filler
Home health care can provide important gap fillers for patients transitioning home after exacerbation of a chronic illness, after surgery, or a new diagnosis. Since hospital stays are so short, patients leave hospitals at a minimum level of recovery and need support as they continue to recover in the home. This gap period is especially critical during the period between discharge and when the patient has his or her first physician appointment in the community. During this time period, which can be a week or more, patients may not fill prescriptions they receive upon discharge from the hospital, may not follow diet or activity restrictions properly, or may make errors in medication administration. These errors and/or omissions in care can result in return visits to the emergency room and possibly readmissions to the hospital.
When hospital lengths of stay were longer, home care played a lesser role than it does today. Today, case managers should consider a home care referral for virtually every discharge they have, particularly older patients or those with chronic conditions. In some instances this may mean one home care visit for medication reconciliation, or it may mean a longer-term relationship between the patient and the home care services.
Reducing Readmissions to the Hospital
As listed above, there are many factors affecting hospital readmissions, and good discharge planning can help to remedy some of them. Patients who are going home may, in some ways, be at greatest risk for hospital readmission if the discharge plan is not comprehensive and thoughtful. Therefore, as part of a readmission reduction program, home care referrals should be considered for almost all hospital discharges. This no-cost solution can do much in reducing your hospital readmission numbers if thought out carefully.
You may need to develop a data management structure if you do not currently have a case management software program to help collect information on the causes of your hospital¡¦s readmissions. The data can become part of your monthly case management report card. The readmission rates should be reported as percentages. For example, what percentage of all your readmissions were heart failure, pneumonia or acute MI? How many of these readmissions did not have a home care referral? How many other patients did have a home care referral but did not actually receive the home care services?
We know that among the top root causes for preventable readmissions are the following:
- The patient did not see his or her physician within 7-10 days of discharge.
- The patient did not accurately follow his or her medication regime once discharged to home.
- The patient was confused or unclear as to how to manage his or her disease process in the home setting.
- No home care was arranged for the patient after discharge.
Discharge Assessments
The root causes of any one of these issues probably involve the hospital discharge planning processes as well as the process of transitioning the patient to the home or other setting. Because of this, case managers are in a unique position to ensure that the patient moves smoothly, safely, and well-planned to the next level of care. One of the most effective ways to accomplish this is to be sure that every patient is assessed for discharge planning purposes. Singling out only specific types of patients for a case management assessment will undoubtedly result in some home care-worthy patients being missed, thereby increasing their statistical chances for readmission.
Contemporary case management models call for a discharge planning assessment to be completed on every patient. This process should begin on admission and continue to be re-evaluated every day that the patient is in the hospital. Case managers should include a list of guiding points to help them identify which aspects of the patient¡¦s condition may qualify for home care services. If this list is built into the case management admission assessment form, the case manager can have a greater assurance that no patient who qualifies for home care will be overlooked. It is recommended that you review this list each and every time you begin the discharge planning process for a patient. In addition, if the patient does not initially appear to meet the home care criteria, you should circle back to the list throughout the hospital stay so that any changes in the patient¡¦s needs or condition will not be overlooked.
Assess Every Patient
So, it is vital that you assess EACH AND EVERY patient on admission and throughout his or her stay. Standardize your discharge planning process by developing a case management assessment form. The form should include all relevant data sets needed to make a comprehensive determination as to what services the patient will need once discharged from the hospital. Then be sure that the patient is reassessed daily or as frequently as possible. This can be accomplished on daily walking rounds where the case manager can discuss the current clinical issues as well as transitional care needs without adding any additional time to the process. It is during these assessment points that the case manager can ensure that the best plan is being developed for the patient¡¦s next level of care needs and requirements.
As you develop your standardized tool, be sure to include all the key elements for an initial evaluation of the patient as it relates to home care services. These elements are listed below. If patients meet any of these criteria, they should qualify for home care, assuming they have insurance coverage for the service. Familiarize yourself with the list in the box on page 152 and review it each time you admit a patient. Leaving this to your memory will increase the chance of missing an eligible patient during your assessment.
Medication Errors
Of note are the criteria in the first bullet: ¡§New medications or change in medications.¡¨ As we discussed above, medication errors happen frequently in the home. These errors may include taking the wrong dose, skipping doses, or not filling the prescription at all. Patients may be confused by dosage changes that happened while they were in the hospital. For example, a heart failure patient may have been on Lasix 10 mg prior to admission and is now discharged on 20 mg. When the patient returns home, he or she will have both dosage vials and may either mix them up or think they are the same, thereby resulting in an error. Or the patient may think that he or she already has the medication and not fill the new prescription at all, or want to use up what he or she has. While well-intended, any of these errors may result in another exacerbation of the patient¡¦s heart failure and another return to the emergency department and possibly an admission back to the hospital.
As you assess your patient, think carefully about this. Even educated patients can make mistakes or become confused by changes to their routine. For some, one home care visit for medication reconciliation in the home may be all they will need. However, this one visit may be crucial to their successful management in the home.
Frequently Readmitted Patients
Another set of criteria of note is ¡§patients re-hospitalized within 60 days and/or known history of repeated hospital readmissions.¡¨ While we typically focus on patients readmitted within 30 days, you may also want to look at patients who fall into the 60-day category as well. These patients may also benefit from home care services to ensure that their care plan, including medication management, is implemented in the home. Be sure to identify the root cause of the readmission(s) and to focus on this when making the home care referral. The more information you can provide to the home care agency, the more likely that the patient¡¦s needs will be met in the home and he or she will not return to the emergency department for a preventable reason.
Most of the other referral criteria on the list above are more obvious, as they relate to the patient¡¦s clinical condition or change in clinical condition. Medication management and readmissions may be less obvious and require that you think of the home care referral process in a new way.
For each patient example or issue we have raised, a home care referral may have made the difference between a positive and a negative outcome. Build these criteria into your assessment form to ensure that no patient is missed or overlooked.
Homebound Status
Another issue has to do with the myths surrounding the category of ¡§homebound.¡¨ Physicians, nurses, and case managers are often confused by how this is defined. Even some nurses in home care may not fully understand what Medicare actually means by this term. You may find yourself not making a home care referral because you consider the patient not to be homebound. The elements listed at the top of the next page provide a framework for what Medicare considers homebound status. Patients can leave home, but leaving home must take a considerable effort on their part. Examples of this are below as well as the types of reasons as to why patients can leave their homes and still be considered homebound.
Check on Your Patients After Discharge
Calling patients after discharge is the final step in the discharge planning process for the hospital case manager. Every attempt should be made to call patients within 48 hours of discharge to ensure that the plans for discharge are in place. When calling patients, below are some key questions you should consider asking them:
„Ï Did home care arrive?
„Ï Did durable medical equipment (DME) arrive?
„Ï Are you taking your medications as prescribed?
„Ï Do you have any questions regarding your medications?
„Ï When is your next doctor¡¦s appointment?
„Ï Do you have a way to get to that appointment?
„Ï Do you have any questions?
By making these follow-up calls, you will be able to confirm that your discharge plan is in place and that the patient is adherent to the interventions you planned for in the community. Most important among these is medication management and the physician follow-up appointment in the community.
Measuring Your Results
One of the metrics your department should track and trend every month is a measurement of how many patients leave the hospital with home care services in place. Your goal should be to have more patients going home with home care services and fewer patients going home with no services. By measuring these metrics as percentages of total discharges, you can begin to get a sense of how many of your patients are receiving these services in the community. Your benchmark should be your prior year¡¦s performance in the category. The target should be based on the improvement you want to make for the new year. For example, in the prior year, 12% of your patients may have been discharged with home care services. This would be your benchmark. For the new year, you may want to improve this by 10%, so your new benchmark would become 13.2% or an improvement of 1.2% of discharges.
Summary
Home care is an important intervention to consider for virtually every patient you discharge to home. By using the strategies discussed above, you can increase your percentage of patients going home with this important service. Remember to assess every patient on admission and to reassess every patient daily. Standardize your assessment questions using a tool that includes social work and home care referral criteria. Finally, consider home care as one of the most important tools in your readmission reduction toolbox!
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