Post-discharge care by a home health partner can prevent a rehospitalization
Hospital readmission rates have been in the spotlight due to the high cost of avoidable, often duplicative care. In particular, Medicare patients have a 16.9% readmission rate within 30-days of discharge, which typically costs $15,500, and does not include the cost of time and discomfort to patients and their families. Providers can reduce their readmission rates by improving discharge planning with the help of a home health partner.
The right home health partnership gives providers greater peace of mind, knowing that the patient’s post-discharge care team will aid in their recovery and focus on preventing possible rehospitalization. Below are four ways that Constellation Health Services partners with providers to keep patients out of the hospital.
1. Interdisciplinary Care Teams
We pair patients with an interdisciplinary team that consists of providers and staff equipped to care for them at any stage or level of care. When developing customized care plans for our patients, we assemble an interdisciplinary care team who will help our patients succeed in their treatment.
Our care teams can include, but are not limited to:
- RN Case Managers
- Physical Therapists
- Occupational Therapists
- Speech Therapists
- Social Workers
- Home Health Aides
When needed, our teams bring in nurse practitioners to help with case management and ensure patients are receiving the right treatment from the comfort of their homes.
“Our nurse practitioners are empowered to intervene to keep the patient home and have the ability and bandwidth to contact other providers in the patient’s care team to coordinate additional care that the patient may present for during our visits.” – Christine LeBrun, Nurse Case Manager at Constellation
2. Focusing on the Social, Environmental, and Emotional Aspects of Patient Health
The right home health partners look to the patient’s wider social, environmental, and emotional needs to care for the whole person. Once home, there are many elements that can impact a patient’s recovery and are often overlooked while patients are in a hospital. Access to proper nutrition or exposure to fall hazards, for example, are factors our care teams look out for to promote healthy recovery and prevent rehospitalization once patients return home. Our care teams also assess the mental and emotional health of our patients and can provide support and referrals to specialists when appropriate.
Here are a few ways that our care teams address a patient’s social, environmental, and emotional needs.
- Ensuring patients have transportation to receive their medications and attend their follow-up appointments.
- Evaluating the patient’s access to mobility aids like ramps and grab bars that reduce the risk of falling at home.
- Checking the patient’s food supply to make sure that the patient has access to the proper nutrition that promotes recovery.
- Set up delivery services to ensure supplies are available to the patient.
- Support and educate family members and caregivers so patients have the support they need to recover in comfort.
We use a range of technological solutions to amplify the impact we have on our patients’ recovery. We connect patients with their loved ones virtually and bring remote monitoring technology into the patients’ homes.
By giving providers access to patient-generated health data, we can monitor our patients’ health metrics from anywhere, at any time. This information is seamlessly relayed to our care teams when they are away from their patients, encircling patients with caring oversight at all times. With remote patient monitoring devices, we can respond to changes quickly and help prevent any new symptoms from worsening.
Even with the right care teams and technology, there is still room for error. Care teams must be responsive to their patient’s needs and provide interventions before the patient requires readmission or even an ER visit. Factors that impact the responsiveness of the care team include adequate staffing, company policies and procedures, and patient and family education on action plans if there is a health event that requires immediate attention.
At Constellation, our care teams incorporate all of these elements to fulfill our mission of providing compassionate care at home and preventing hospitalizations. When working with patients, we surround them with the support and care they need to recover in comfort.
Constellation Health Services is an award-winning, value-based home health care agency serving the Northeast. At Constellation, our goal is to provide a comprehensive stay-at-home health solution for your patients that includes a team of trained professionals, a suite of technology services, and coordination of in-home diagnostic and delivery services. We help partners achieve an average savings of 10% by avoiding rehospitalization penalties and reducing nursing home utilization and length-of-stay. Contact us and learn more.