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How Home Health Agencies Use Technology to Reduce Readmissions

Importance of Reducing Readmissions
In order to decrease readmissions and related costs, the Hospital Readmissions Reduction Program (HRRP) was established as part of the Affordable Care Act. Between 2010 and 2016, CMS reduced Medicare payments to hospitals with excessive readmissions within 30 days of discharge for certain conditions by over $2 billion dollars.

As a result, hospitals are focusing on how post-acute care (PAC) – specifically, home health agencies – can help reduce readmissions.  When evaluating agencies for PAC care referrals, hospitals are prioritizing those agencies who have been able to demonstrate a reduction in readmissions as well as an improvement in clinical outcomes.

Opportunities for Virtual Care Technology
Home health providers are able to help hospitals reduce readmission rates, especially during the critical 30 days following discharge from hospital. Virtual care communication platforms are increasingly utilized to help home health agencies improve patient outcomes and reduce readmission rates in the following ways:

  1. Connect with patients early, especially pre- and immediately post-discharge.   With a virtual care platform, home health providers can be introduced to the patient before the patient is discharged, setting expectations on the follow-up appointments.  After discharge, the provider can use video and messaging to monitor progress and motivate the patient to adhere to the medication plan and lifestyle changes on a regular basis.   
  2. Incorporate specialists (such as a clinician and/or pharmacist) to address patient questions.  According to the Centers for Disease Control and Prevention (CDC), adverse drug events cause approximately 1.3 million emergency department visits each year. About 350,000 patients each year need to be hospitalized for further treatment after emergency visits for adverse drug events. People typically take more medicines as they age, and the risk of adverse events may increase as more people take more medicines. With a virtual care platform, home health providers can include additional providers who can answer patient concerns which are outside the realm of the home health provider without requiring the patient or the specialist to travel to a different location.
  3. Drive understanding amongst patients with language barriers.  Discussing important care instructions to patients is vital to prevention of readmissions.  Patients who are part of the Limited English Proficient population may miss vital information, impacting outcomings and readmission rates. With a virtual care communication platform, a home health provider can quickly introduce an interpreter into the video call to deepen patient understanding. Messaging at each touchpoint can also be translated into the patient’s primary or preferred language.
  4. Bring in the patient’s family (whether near or far) into the video-based virtual visits.  Involving family members in the care, support, and communications will help the patient transition from inpatient to outpatient and also strengthen understanding and commitment to the care plan.  A virtual care platform offers patients’ out-of-town family members a convenient way to become involved in their loved ones’ care, thus alleviating the guilt often associated with not living close enough to provide hands-on support.
  5. Identify the patients at risk for readmission.  Recognizing which patients are not responding to the home health agency’s communications ensures that emerging health issues do not go unnoticed. With the virtual care platform’s dashboards, home health administrators can see which patients are engaged in their care and arrange for an immediate interventions in the home,  preempting unnecessary and costly ER visits, transfers, and readmissions.  
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