Home Health & Hospice

Homecare Plays a Vital Role in Care Transitions

Homecare Insider, April 18, 2011

The term care transitions refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Homecare providers play a vital role in the transition of patients from inpatient facilities to home and from home to inpatient facilities. These transitions should be efficient and effective, meeting the unique needs of each patient. Communication is a valuable component of care transitions and homecare providers are often pivotal in initiating that communication.

Now, the Centers for Medicare and Medicaid Services (CMS) is initializing the Partnerships for Patients, a new national patient safety initiative to address preventable injuries and complications in patient care over the next three years. Part of that initiative, is the Community-based Care Transitions Program which provides funding to test models for improving care transitions of high-risk Medicare patients. The goals of this program are to improve transitions from the inpatient hospital setting to other care providers, improve the quality of care, and reduce rehospitalizations for high-risk patients, while documenting savings to the Medicare program.

In improving care transitions, homecare providers can:

  • Improve communication with inpatient discharge planners to improve inpatient discharge coordination, encourage better discharge planning and discharge risk assessment, and suggest use of a discharge preparation checklist.
  • Identify medication discrepancies, offer early medication education, including the use of a patient medication record, and encourage self-management of medications.
  • Engage patient and family in planning care and setting realistic goals.
  • Initiate early education on disease and response to signs and symptoms of complications or worsening condition. Ensure patient has knowledge of “red flags” to identify and whom to contact. Develop an emergency plan and educate patient and family on how to follow that plan.
  • Encourage use of personal health records and regular physician follow-up.

Homecare providers are in a prime position to improve care transitions and the first step is improving communication with other healthcare providers, thus forming a team to work for the benefit of the patient. That team should include the homecare team, the patient and family, the physician, and other healthcare providers involved in the patient’s care.

The audio conference series, “Reduce Rehospitalizations through Effective Care Delivery,” addresses care transition tips and other techniques that help reduce rehospitalizations.  Learn about this audio conference series today!