How Virtual Care Helps Home Health Agencies Partner with Post-Acute Care Facilities

Home healthcare is not limited to supporting at-home patients. Patients may be receiving home healthcare services whether they are living at home, temporarily residing in a post-acute care facility, or residing in a longer-term care facility.  Home health agencies are increasingly working with care facilities – such a SNFs and ALFs – to provide needed care for their residents while helping these residents remain in these facilities instead of being readmitted to a hospital or being transferred to a higher level of care. 

According to a study in the Annals of Long-Term Care, an emphasis on decreasing the duration of a hospital stay and the related risk of hospital readmissions is leading to an increase in admissions to post-acute care facilities.  Hospitals are transferring patients instead of discharging patients directly to their home because a transfer to a post-acute care facility can take place more quickly than a direct discharge home – resulting in less time spent in the hospital. Also, a post-acute care facility leverages professional caregivers to provide greater oversight, decreasing the risk of re-hospitalization.   

Home health staff are part of the professional caregiver network valued by post-acute care facilities because of their role in providing patients with compassionate, comprehensive care – in a more familiar setting.  Although agencies may work within a care facility, the SNF medical director or the ALF provider remains responsible for each resident.  As communication is a critical element of this partnership, a virtual care communication platform can help drive better understanding and alignment amongst in the home health / care facility partnership. 

  • Given this context, the agency can use a virtual care platform to ensure impactful and immediate communication amongst the facility, the agency, the resident patient, and the patient’s family caregiver throughout the continuum of care. 
  • A facility’s clinician can be “present” more frequently via video; additional clinicians and specialists can also connect with the patients and visiting nurses to ensure that the patients is receiving the care they need without requiring a transfer back to the hospital or to a higher level of care.
  • When a change in the care plan is initiated, the agency’s care team member can conduct virtual meetings to inform all stakeholders about the rationale for the change and the next steps.
  • The patients’ out-of-town family members can be kept in the communication loop – whether via video, text, and/or email – and alleviate the guilt often associated with not living close enough to provide hands-on support.  

Virtual care communication platform can also help home health agencies reinforce the reputation of post-acute care facilities. Post-acute care facilities value partners who can help minimize the “revolving door” of readmissions and improve overall outcomes.  Home health often provides an important link in recuperation and transition from a post-acute care stay to restored independence at home.   

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