Post-Discharge Home Visits, SNF Visits Halve Readmissions for High-Risk Population

Monday, April 27th, 2015
This post was written by Patricia Donovan

In an Ohio care transitions management initiative, post-discharge home or SNF visits to Medicare beneficiaries at high risk for readmission have helped to curb rehospitalizations by nearly 50 percent.

As one of CMS’ Community-based Care Transitions Program (CCTP) demonstration projects, field coaches for the Council on Aging (COA) of Southwestern Ohio conduct home visits for high-risk Medicare fee-for-service patients in nine partner hospitals, explained Danielle Amrine, the COA’s transitional care business manager during an April 2015 webinar, Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, now available for replay.

The COA of Southwestern Ohio completed 10,202 home visits from June 2012 through 2014, Ms. Amrine said. “The national readmission rate is around 21.3 percent. Those patients involved in our CCTP program experienced a readmission rate of 10.48 percent.”

Home visits occur within 24 to 72 hours of a patient’s discharge from the hospital; SNF visits within 10 days, to allow the patient to settle in at the SNF. For SNF visits, made to the top 10 nursing facilities where patients most often discharged, field coaches utilize the LACE readmissions tool to assess the need for a home visit post-discharge.

The intervention is designed to empower patients of any age and their caregivers to assert a more active role during their care transition.

Reinforced by a trio of follow-up phone calls, a typical home visit lasts about one hour. While geared to the patient’s needs, the visit always covers the crucial medication reconciliation, which allows the coach not only to assess the patient’s role in managing their medication regimen but also to identify any medication discrepancies. Medication misunderstandings are particularly common during transitions in care.

In a recent month, COA coaches identified 77 medication discrepancy issues, which, once resolved, resulted in only four of these patients from being readmitted back to the hospital.

The Southwestern Ohio program, the second in the nation to be funded by CMS to conduct home visits, is modeled on the four pillars of Eric Coleman’s Care Transitions Intervention®. However, the COA has added a fifth pillar, community services, to connect patients to the COA’s broad range of in-house and community-based services during the critical transition between providers or care sites.

The program relies heavily on personal health records (PHRs) to facilitate cross-site communication and ensure continuity of care data across practitioners and settings.

Success from the COA care transitions initiative also extends to emergency department utilization by this population: the national average baseline is around 11.6 percent, and CCTP participants show an admission rate of 9.39 percent, Ms. Amrine added.

About 15 percent of scheduled home visits do not occur; the program has created a number of strategies to address this falloff.

Future enhancements by the COA of Southwestern Ohio program include a behavioral health intervention and a pilot in which University of Cincinnati College of Pharmacy interns will reconcile medications via Skype® or other telemedicine application.

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