From Collaborative Healthcare Strategies, Lexington, MA (Dr. Boutwell), and the National Home Health Corporation, Scarsdale, NY.
Abstract
- Objective: To describe a quality improvement initiative implemented by 2 home health care agencies to reduce readmissions.
- Methods: The agencies reviewed their data and identified best practices for reducing acute hospital transfers among their high-risk heart failure patients, focusing on the first 14 days of the care episode. Care intensity was increased during the first 3 days, and an active surveillance approach was used during the first 2 weeks. Training for staff, called “Heart Failure Boot Camp,” was introduced and made part of new employee orientation.
- Results: The 30-day rehospitalization rate was reduced from 31% to 17%.
- Conclusion: A data-driven transitional care model can lead to reductions in 30-day readmissions among high-risk patients receiving home health care.
Hospital readmissions are frequent, costly, and can be a marker of poorly coordinated postdischarge care [1]. Since the passage of the Affordable Care Act in 2010, reducing readmissions has become a national priority, as reflected in the emergence of accountable care organizations, bundled payments, and readmission penalties for hospitals, among other efforts. With the increasing attention on reducing readmissions, home health care agencies are under pressure to identify opportunities to improve performance. Two affiliated home health care agencies in Massachusetts and Connecticut made reducing their all-cause 30-day readmission rate a strategic priority. In this article, we describe their approach.
Setting
New England Home Care (NEHC, Cromwell, CT) is a regional agency that serves 7 of the 8 counties in Connecticut and over 7400 patients annually. Medical Resources Home Health (Newton, MA) is a regional agency that serves 8 of the 12 counties in Massachusetts and 2000 patients annually. These home health agencies are both owned by National Home Health Care Corporation (Scarsdale, NY) but are independently managed, with separate staff and regional market differences.
Data Analysis
NEHC data from 10/1/2011 to 9/30/2012 showed that the rate of acute care hospitalizations within 30-days of the initiation of an episode of care for their heart failure patients was 31%. They found that 50% of hospitalizations occurred in the first 14 days of the episode, with the greatest risk occurring in the first 3 days ( Figure). The most common diagnoses leading to readmissions within 30 days were heart failure, respiratory infection, and other respiratory problems. They also analyzed their data to determine if there was regional variation among agency offices with the intent to understand if local factors such as staff practice patterns, local availability of care, relationships between home health and physician practices, etc. might identify opportunities for improvement.
Opportunities for Improvement The data analysis highlighted several immediate opportunities for improvement. First, the data showed that the first 3 days of the home health episode are a period of increased risk. Thus, intensification of care—and successful first contacts—during the first 3 days of the home health episode was an important target goal. Similarly, the first 14 days were a period of increased risk, suggesting the potential benefit of home health staff proactively monitoring patients during this time to identify clinical or other needs early in the effort to avert a hospitalization. In addition, while respiratory symptoms were among the top reasons for acute care hospitalization within 30 days of episode initiation, many other diagnoses were also implicated. Nine conditions comprised 80% of coded reasons for hospitalization, suggesting that vigilance around respiratory complaints is important but cannot be the exclusive focus of symptom management in this population.