by Tim Rowan, Editor
A couple years ago, we described a highly successful program to move patients from sometimes lengthy hospital stays back to their homes. Conceived and operated by a Colorado not-for-profit, "Hospital-to-Home" saved tens of thousands for the participating hospital, earned thousands for the home health agency, and improved patient outcomes and outlook on life. (See Rowan Report, July 31, 2019: "Hospital-to-Home Program Saves Lives, Slashes Costs")
This week, we heard about another program that sounded similar...at first. Upon closer examination, however, it turned out to be both radically different and somewhat disappointing.
The Healthcare Intelligence Network is offering a 25-page book ($89) titled, "Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients." In it, Danielle Amrine, transitional care business manager at the Council on Aging of Southwestern Ohio, describes her organization's home visit intervention, which is "designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care." (emphasis added)
The stated philosophy behind the 5 Pillars is that "timely home visits following patients' discharge from the hospital offer patients tools and support that promote self-management and reduce the likelihood of readmission to the hospital." Familiar language, no?
HIN's summary of the pamphlet's message serves substantially as the definition of the difference between "Hospital-to-Home" and "Hospital-at-Home." The former taps the 120-year experience of visiting nurses and non-clinical caregivers to give a person with one or more chronic conditions or a disability an option to a lengthy hospital stay. The latter deploys hospital nurses and other personnel to homes in an attempt to recreate there a hospital's atmosphere and services.
The former engages an important sector of the healthcare system by asking it to do what it does best, what it does better than any other sector. The latter ignores visiting nurses and puts hospital staff into an environment with which they are completely unfamiliar.
Promotional materials for the booklet say that the Council on Aging developed the hospital-at-home program to provide "home visits intervention, in which field coaches conduct post-discharge visits to patients at home and/or within skilled nursing facilities." It goes on to state what home health and home care providers know, "Poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and the inappropriate use of hospital emergency and post-acute services."
Promotional materials go on to state, "The COA is a member of the Southwestern Ohio Community Care Transitions Collaborative, the second program in the nation accepted into CMS's Community-Based Care Transitions Program. The goals of the CMS CCTP are to: improve transitions of beneficiaries from the inpatient hospital setting to other care settings; improve quality of care; reduce readmissions for high-risk beneficiaries; and document measurable savings to the Medicare program." More things VNAs, Home Health Agencies, and Home Care providers also know well. If they had only asked us.
©2021 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Home Care Technology: The Rowan Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org