Beginning in October of 2012, the Social Security Act established standards for the Hospital Readmissions Reduction Program (HRRP) in an effort to measure and increase the quality of care at hospitals across the country. The 21st Century Cures Act of 2019 further refined the process, where hospitals with comparable numbers of patients on Medicare and Medicaid could be measured against each other. The Centers for Medicare & Medicaid Services (CMS) could adjust payments to hospitals based on their performance.

The implications of this, of course, have brought readmission rates to the forefront for administrative and care teams. While it is undoubtedly a positive move to use objective measures to spot problems and make changes for better care—especially of vulnerable populations like elderly patients or those with chronic conditions—care professionals know that readmission happens for myriad reasons that have nothing to do with a hospital’s neglect. Patients are readmitted because they forgot part of their discharge instructions, or because they have no one around to check whether they have taken their medication. They become dehydrated, miss follow-up medical appointments or trip and fall at home. All of these risks are mitigated by one powerful resource, which is home care.

HOME CARE AS HRRP STRATEGY

We know that home care makes a measurable difference in the physical and emotional well-being of patients. Beyond simply meeting daily needs and covering ADLs, home care means regular safety checks and companionship. It means respite for families who daily provide hours of unpaid care for a loved one while balancing work, their own children’s care and other demands on their time and energy. Home care brings peace of mind and relief to families with a loved one affected by dementia, impaired mobility or with complex health needs.

There are four facets to home care as HRRP strategy:

1. It allows a care professional to closely monitor the highest-risk patients. Becker’s Healthcare has found that the patients at highest risk for hospital readmission are those who were hospitalized for heart failure, acute myocardial infarction and pneumonia. These patients are readmitted after a median 10-12 days from discharge, with over 60% readmitted within 15 days.

Hospital readmission is measured within 30 days of discharge, for any reason (not necessarily what caused hospitalization in the first place). Home care for at least 30 days after discharge ensures quick response to symptoms that might arise, hopefully preventing the need for readmission. Patients can be treated quickly in other settings, precluding escalation and crisis situations.

2. A trained professional evaluates the patient’s situation holistically, addressing potential threats of different kinds. Care professionals know to look for signs of mental distress, dehydration, malnutrition, hidden injuries and household threats such as broken air conditioning or tripping hazards. They can review discharge instructions and make sure they are followed. They can also facilitate communication between the patient and their family, filling in knowledge gaps on both sides in an effort to ensure the patient is safe and improving in health.

3. Caregivers hold a wealth of experience in supportive tools for patient safety and well-being. This can include therapeutic and strengthening exercises, mobility/hearing/vision aids and emerging technologies that others are using for help with ADLs, communication or supervision. A professional caregiver has many more resources at their disposal than the average untrained family member.

4. Caregivers and agencies have thoughtfully, systematically designed processes and procedures that anticipate the common needs of patients and care clients. Beyond simple compliance, the most successful agencies are able to provide evidence that they are responsive to the needs of the populations they serve—and they are able to show patterns of improvement. There is a direct line from these agencies’ goals and metrics to those of HRRP.

CMS sends Hospital-Specific Reports (HSRs) to hospitals every year. These reports collect HRRP data and are the basis for Medicare fee-for-service payment reduction (where applicable). Though hospitals can dispute calculations in these reports, they cannot dispute any claims or data they contain. CMS also provides a searchable database of their data on hospitals, doctors, dialysis facilities, rehab facilities and more. This makes HRRP measurement and vigilance a priority.

With stakes this high, home care agencies can be further incentivized to show healthcare partners how they can help them keep their trends positive.

WHY DON’T ALL PATIENTS DISCHARGE FROM HOSPITAL TO HOME CARE?

In a perfect world, every elderly pneumonia patient would be discharged straight into home care, where they could be constantly monitored and assisted with all their health and daily living needs. But we know that this is not the case.

Overwhelmingly, the reason is cost. Home care can be cost prohibitive for many families, leading them to try to stand in the gap themselves. The problem is, they are already overcommitted and are untrained for the task. And then there are patients who do not have family, or family nearby. They are largely left alone after discharge, putting them at greater risk of readmission.

Besides discharging to a skilled nursing facility (Werner, et al., 2019), discharging to home care affords patients the best outcomes. So what are families and their social workers or case managers supposed to do next? Short of dipping into savings or acquiring debt, the solution is to find any benefits for which their patient may qualify. The authors of this article represent Veterans Home Care, an organization that works with U.S. military veterans to claim the VA’s Aid and Attendance benefit. Regional Director Dana Taylor, LCSW, presented on this benefit at CMSA’s 2023 Annual Conference. VHC was founded in 2003 by Bonnie Laiderman, who had faced the problem of inaccessible home care for her own mother and established a tight and well-supported process called VetAssist to bring an underutilized veteran benefit to more families in situations like hers. (You can learn more by visiting the Aid and Attendance page or the blog on veteranshomecare.com.)

As Taylor noted to a sympathetic audience at the CMSA conference, benefits to assist with healthcare costs are not easy to come by. Employing a knowledgeable network and expanding one’s toolkit with benefits such as Aid and Attendance and other VA opportunities are one way to bring the increased safety and comfort of home care to more vulnerable individuals in an effort to cut their odds of readmission.

REFERENCE

Werner, R. M., Coe, N. B., Qi, M., & Konetzka, R. T. (2019). Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility. JAMA internal medicine, 179(5), 617-623. https://doi.org/10.1001/jamainternmed.2018.7998

dana taylor

Dana Taylor, LCSWis a Veterans Home Care regional director. Taylor routinely meets with professionals from home care agencies, hospitals and veterans’ organizations as a subject matter expert on the VA Aid and Attendance benefit. She also works directly with veterans and their families. For any questions you may still have, you can email Dana Taylor at .

 

sylvia trein

Sylvia Trein is a freelance writer and editor reporting on diverse topics in healthcare, tech, consumer research and insights and not-for-profits. She is based in Greenville, South Carolina, and Fort Lauderdale, Florida.

Veterans Home Care is a private company, not affiliated with the VA or any government agency. Their VetAssist Program offers in-home care and other services right away with no out of pocket costs and no waiting for VA funds to arrive for those who qualify.

IMAGE CREDIT: JACOB LUND/SHUTTERSTOCK.COM