8 Ways Home Healths Can Reduce Hospital Readmissions

Sarah McIlvaine
Author | Shield HealthCare
10/19/16  2:02 PM PST
reduce hospital readmissions

Changes in the healthcare setting are increasing pressure on medical providers and hospitals to partner with companies that will help improve patient outcomes and reduce hospital readmissions. A recent report from the Centers for Medicare and Medicaid Services (CMS) announced that 49 out of 50 US states reduced their readmission rates since 2010.

Home care providers are able to help hospitals reduce readmission rates during the critical 30 days following discharge from hospital. As a result, home care referrals are being given with positive patient outcomes in mind. Here are a few ideas for improving patient outcomes and reducing readmission rates:

1. Know which patients are at risk for readmission.

According to a 2008 study from Baylor University Medical Center, here are the top risk factors for 30-day hospital readmission in patients sixty-five years and older:

  • Older age
  • Male sex
  • African American race
  • Medicare-only insurance without supplemental health insurance
  • Medical service admission
  • Major comorbid conditions including: certain cardiovascular diseases, chronic lung disease, renal failure, cancer, pneumonia, and diabetes mellitus
  • Discharge to long-term care*

* Discharge to long-term care was the highest risk factor found in this study.

2. Ensure all staff are aware of patients who are at higher risk for readmission. 

Make sure all your staff is aware of significant risk factors. Generate a special protocol for monitoring and treating high-risk patients that all staff members are aware of.

3. Take special care when communicating with patients who have language barriers. 

Communicating important care instructions to patients and their caregivers is vital to prevention of readmissions. A language barrier can lead a patient to miss vital information and could result in a hospitalization. Check for understanding, find a translator as needed, and overcome challenges to keep in touch with these patients.

4. Visit patients early and make sure they complete necessary physician follow-ups.

Help patients make appointments and organize transportation as necessary. Regular follow-ups will help reduce the likelihood of adverse drug events (see #8).

5. Clearly communicate care instructions to the patient.

Clear communication with patients is a significant step toward avoiding the cost of preventable readmissions. Care providers can teach an individual how to recognize their own symptoms before they get worse, and which actions to take to prevent worsening of these symptoms. Clear communication is also key to improving patient satisfaction and quality of care ratings. 

An example of the benefits of patient communication comes from UCSF Medical Center, where a team of heart failure experts monitored heart failure patients after discharge. The team implemented a strategy of educating the patients about their disease, and using the “Teach Back” method to check understanding. The “Teach Back” method involved asking the patient to repeat what they have learned in their own words. The educational approach helped reduce readmissions for heart failure in senior patients by 30 percent. 

6. Install telemonitoring technology in the homes of chronically ill patients.  

Monitoring high-risk patients using remote technology ensures that sudden health changes do not go unnoticed. This allows for immediate interventions in the home, before the issue progresses to a point that warrants a visit to acute care or the hospital.

7. Specialize in treatment of certain conditions or diagnoses.

Some home health agencies have begun to specialize in treating patients who are at higher risk for readmission. For example, home care franchise company Interim Healthcare has developed marketing strategies that focus on care for patients with heart disease. They include special services for these high-risk patients such as: planning and preparing a heart healthy diet, shopping and meal preparation as needed.

8. Fill and reconcile prescriptions as soon as possible after hospital discharge.

According to the American Academy of Family Physicians (AAFP), one in six hospital admissions of older adults is the result of an adverse drug event. More than half of adverse drug events are the result of dosing, and therefore may be preventable. Adverse drug events are more likely as the number of medications the individual is taking increases. Some methods to reduce the risk of adverse drug events include:

  • discontinuing medications
  • limiting the prescribing of new medications
  • reducing the number of clinicians prescribing medication
  • frequently reconciling prescriptions
  • providing medication reminders
  • assisting with administration
  • Criteria that may help identify medications that cause adverse drug effects include:
    • STOPP (screening tool of older persons’ potentially inappropriate prescriptions)
    • Beers
    • START (screening tool to alert doctors to right treatment)


Institute for Health Care Research and Improvement at Baylor Health Care System

Healthcare Finance News

Becker’s Hospital Review

National Center for Biotechnology Information

Quality Insights Pennsylvania (QIPA)

HIT Consultant

American Academy of Family Physicians (AAFP)

For more information, see related articles and resources here:

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