This document discusses how home health care can help reduce hospital readmissions. It notes that 10-25% of inpatient discharges result in readmission, with over half of Medicare readmissions related to circulatory diseases. Home health agencies can help through nursing assessments, health teaching, and clinical interventions after hospitalization. The document recommends selecting agencies based on outcome measures reported on the Home Health Compare website, such as management of heart failure symptoms and improvement in ambulation. It provides an example of the type of results reported but does not endorse any specific agency.

1. Utilization trends
in home health
Rebecca Byrd, RN
Techota

2. Goals
● Explain how home health care can reduce
rehospitalizations
● Discriminate between home health agencies
based on publicly reported outcome measures
● Summarize outcome measurements using
OASIS

3. The problem of rehospitaliation
● Anywhere from 10-25% of inpatient discharges
will be readmitted
● Medicare patients have a higher readmission
rate
● More than half of Medicare readmissions
related to circulatory diseases (Jiang and Wier,
2010)
● Financial penalties for high readmission rates
start 10/1/12 – thank you ACA!

4. Hospital Readmissions Reduction
Program
● Outside the scope of this presentation
● Probably something you're already familiar with
● If not, exhaustive details are at the CMS
website
● http://cms.gov/Medicare/Medicare-Fee-for-Service-

5. How does home health come into
play?
● IHI (Institute for Healthcare Improvement) found
that the single biggest problem with
readmissions was lack of post-acute care
● Home health provides nursing assessment,
health teaching, and clinical interventions
following hospitalization
● Medication reconcilliation and drug monitoring
are required components of home health care
under federal regulations

6. Selecting a home health agency
● To find the best home health care agencies, do
not rely on the agency's marketing strategy!
● Do your own homework on Home Health
Compare
● http://medicare.gov/homehealthcompare/
● Lets you compare both process measures and
outcomes measures from up to 3 different
agencies (at a time) vs. state and national
trends

7. A brief word about OASIS...
● The Outcome and Asessment Information Set
● Long list of questions that are incorporated into
the admission and discharge assessments
● Keyed into a computer and uploaded to a CMS
database
● Compares each patient's admission vs.
discharge scores to determine outcomes
● Also tracks when patients come in and out of
the hospital

8. Types of Process Measures that
matter most
● Management of heart failure symptoms
● Diabetic foot care
● Drug education
● Fall risk assessment

9. Types of Outcomes Measures that
matter most
● Acute care hospitalizations
● Emergency department use
● Improvement in oral medications
● Improvement in dyspnea
● Improvement in ambulation

10. An example of what
the results look like...
(this is not an endorsement of any particular home
health care agency)

12. THANK YOU!!!
Please email any questions to rbyrd@rubic.com

13. References
Jiang, H.J., and Wier, L.M. (2010). All-cause
hospital readmissions among non-elderly
Medicaid patients 2007. AHRQ Statistical Brief
#89. Accessed at
www.hcup-us.ahrq.gov/reports/statbriefs/sb90.jsp