Affordable Care Act reform focuses on the Hospital Readmissions Reduction Program (HRRP)– a Medicare value-based purchasing program, that reduces payments to hospitals with excess readmissions. It supports the goal of improving healthcare by linking payment to the quality of care provided. As more and more attention is directed to better outcomes and the decreased cost of care, Home Care has the opportunity to shine by offering necessary services for individuals in their home. First, it’s essential to understand the variety of factors that contribute to rehospitalizations in order for services to be tailored with the goal of mitigating risk.
A few of the known factors that contribute to hospital readmissions are:
- Functional decline without proper intervention
- Issues related to medication management
- Cognitive impairment
- Health literacy
- Adherence to discharge care plan
- Social determinants, e.g., economic factors, transportation, lack of food, lack of support system
Studies have shown that the increase in unmet social needs can correlate to lower quality of health among older adults. Services that home care providers offer help to deter these unmet needs. The initiative to eliminate readmissions is an excellent opportunity for Home Care providers to partner with other healthcare and community entities to assist hospitals in meeting their HRRP goal. Strong relationships between hospitals, certified home health and hospice agencies, and senior living facilities will help community services such as Meals on Wheels be included in the care of more clients. Care coordination is essential to ensure a multi-disciplinary approach is executed to meet the needs of each client. Considerations should include:
- Use of technology for monitoring the client’s health, client reminders, or help with loneliness
- Establishing effective communication routes for all individuals involved in the care of the client
- An understanding that the medical care received shouldn’t be the sole focus– social needs are also fundamental
- Customization of each client’s care plan and regular re-evaluation as the patient’s needs change
MatrixCare is committed to assisting customers in many ways including the ability to track inpatient admissions to generate a usable report. This report can be utilized to provide referral sources with actual data to emphasize the value that their agency offers to clients to minimize the risk of unnecessary hospital readmissions. We also have a Hospital Risk assessment form available to customers.
We look forward to working with our clients to ensure that the necessary data is provided in order for them to be a valuable player in the healthcare community and assist in decreasing hospitalizations.