Though home health is the largest provider type for discharges to post-acute care, many hospitals and health systems do not work collaboratively with home health agencies, or efficiently track patient care once they’re discharged to home health. Partnering with home health agencies should be of just as much importance as partnering with other post-acute care providers, such as skilled nursing facilities; SNFs have a higher cost per patient, but overall spend in home health is actually higher because more patients go to home health.
Unfortunately, rehospitalization rates are higher in home health: a 2019 JAMA study found that readmissions for patients discharged to home health care were 5.6 percentage points higher than for patients discharged to skilled nursing facilities. This may be caused, in part, due to the fact that patients discharged to SNFs are typically tracked more closely than those discharged to home health – and also underscores the need to prioritize home health to reduce readmissions, improve patient outcomes, and better manage home health spend.
Home health patient tracking
To provide home health patients with the appropriate level and length of care for their acuity, hospitals, health systems, ACOs and payers must ensure that their home health partners know who these patients are – whether high-risk or in an ACO or BPCI program – to care for and follow-up with patients accordingly. Through better monitoring of patient care, it is easier to know when – and how – to intervene, which should ultimately improve patient outcomes and reduce unnecessary costs.
CarePort customers use CarePort Connect to track, in near real-time, patients receiving home health care and hospice care. Hospitals, health systems, ACOs and payers can build censuses and worklists for home health patients, and home health agencies can view the same census as its referring hospital. Shared patient data, as well as real-time patient monitoring, allows for intervention of individual patients while at the same time tracking aggregated outcomes and performance across all patients under home health care. Stakeholders can better collaborate around patient care plans and more effectively communicate a patient’s status, such as when a patient is discharged from home health. Patient follow-up once home health services conclude is also critical to ensure that patients – who become accustomed to home health providers regularly visiting their home – understand and take ownership of their care plans in the absence of a visiting caregiver.
Home health patient insights
Not only do hospitals and health networks need to better track patients receiving home health and hospice care, but they also require access to data and measures to enable data-driven conversations to optimize performance within their home health agency network.
CarePort Insight offers a robust home health agency, hospital and health network analytics and reporting tool to help evaluate home health agency performance based on ADT data and across key measures, including timeliness to start of care, admission rates and discharge rates. ADT data, available in real-time, provides valuable in-the-moment directional monitoring that can assist in identifying trends and taking appropriate action – weeks or even months before claims data is available.
Nearly 20% of 30-day hospital readmissions are potentially avoidable, and are in large part influenced by factors including gaps in care coordination, inadequate instructions at discharge and lack of timely follow-up. CarePort Insight provides visibility into timeliness to start of care – a key home health measure – because start of care can influence readmissions and it is critical to ensure that care begins shortly after discharge. Insight also provides hospitals with real-time readmission rate analytics to better determine when patient intervention is required, and how instituted home health programs are performing.
CarePort’s home health offering is a one-stop shop for patient intervention under the care of SNFs and home health, as well as a near real-time tool to monitor performance of home health agencies. To learn how to use home health integration and analytics within CarePort, please contact us for more information.
