Two Home Health Agencies Reduce Readmissions Among Heart Failure Patients Using a Quality Improvement Approach

Conclusion

As rehospitalizations continue to be a prominent measure of quality, cost, and patient experience and a measure for which hospitals and post-acute and community-based providers are either penalized or rewarded, there is a growing awareness of the many factors outside the walls of the hospital that determine whether a patient will return within a defined period of time. Many home health agencies see this as an opportune moment to highlight the critical role they play in care transitions across settings and over time. In this article, we describe the experience of 2 affiliated regional home health care agencies as they engaged in a structured performance improvement effort to reduce readmissions among their high-risk patients. This effort involving data analysis, identification of locally relevant opportunities for improvement, modifications to standard care utilizing existing resources, adding a new service, and expansion beyond the initial target population to all patients at high risk of readmission. This 3-year effort has resulted in a substantial and sustained reduction in rehospitalization rates.