Home Health & Hospice

How Homecare Improves Transition of Care

Homecare Insider, August 1, 2011

Transitions of care have long been discussed in relation to reducing hospitalizations. However, improving transitions of care now also plays a role in obtaining the face-to-face physician encounter documentation. How? By improving their relationships and communication with referring providers, agencies can improve this process, especially when the face-to-face physician encounter documentation is coming from a hospitalist or discharge planner on behalf of the physician.

Transition of care refers to a patient moving from one health care setting to another. The transition involves multiple people and providers including the patient and family, case managers, physicians, and homecare providers. There are challenges to transitions not the least of which are identifying the appropriate resources to meet the patient’s needs, communication, and care coordination. Even after a patient returns home, care transitions can continue as the patient seeks treatment, procedures, and tests. Homecare agencies can play a pivotal role in care transitions before, during, and after their care of the patient. In relationship to the face-to-face encounter, the better relationship agencies have with other providers, the better their chances are of ensuring compliance and cooperation with this requirement.

Homecare agencies can improve care transitions making them more effective and smooth by being involved earlier in the discharge process, improving communication with other health care providers, improving coordination of care, and planning ahead for transitions when possible. Agencies should work to improve, or rebuild, their relationships with hospitals and other care providers to ensure efficient and effective transitions and form partnerships to benefit the patient.

For more information on improving care transitions and hospital readmissions, refer to the new Beacon Health publication “Ending Hospital Readmissions: a Blueprint for Homecare Providers”.