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Today’s healthcare ecosystem requires more collaborative relationships amongst facilities, providers, and settings.  Silos are breaking down as providers and payers work to keep patients at-home vs. in hospitals, SNFs, or LTCFs.  Home health providers which can continue delivering the needed type of care to at-home patients – while preventing costly and unnecessary readmissions – will be critical partners within the value-based ecosystem.

In the Home Health Care Management & Practice journal, a special article titled “The Future of Home Health Care: A Strategic Framework for Optimizing Value” outlined that home health agencies of the future must provide care that is:

  1. Patient and person-centered: Patient-centered care is “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” according to the Institute of Medicine. As the care is provided in the patient’s actual home, home health staff can better reflect and respect the wishes of the patient and his/her family during their visits.
  2. Seamlessly connected and coordinated: Home health agencies must evolve to be seen as partners within the care continuum, connected to primary care and facility-based care and communicating with their peers before, during, and after patients’ episodes of care. As health care moves toward paying for value, visiting nurses will become increasingly critical in ensuring smooth transitions from facility-care to home care, as the patient moves from inpatient to outpatient.  Care coordination is not limited to the needs after a hospital stay or an acute event; home health agencies will ensure they hire and train resources who can additional capabilities that allow the agency to manage care across the care continuum.
  3. High quality: Home health agencies perform a caring, critical, and compassionate role in helping patients’ preference to age in place and remain at home vs. in more expensive care settings. In the future, home health providers will be poised to help patients receive expansive care that is both timely and high quality. Home health agencies could serve as post-hospital and post-emergency department resources for intense episodes of skilled nursing, care coordination, therapy, and related services.
  4. Technology enabled: Technology helps home health providers more easily connect to patients without requiring an in-person visit for each check-in. Virtual care platforms also help these providers access needed care – especially when a patient’s condition changes or a new issue emerges – from clinicians and specialists who would not normally be available for in-person, at-home visits.

Home health providers play a fundamental role in continuing post-acute care. However, visiting nurses’ role in care coordination and collaboration should be initiated before a hospital visit and continue during the hospital stay.  Working with the patient only post-discharge might not be sufficient when making sure that the site of care shifts appropriately from the community to the home.  Technology can be used to both introduce the patient to the home health provider before a home visit and also to integrate the home health provider into the care-related conversations before the patient is discharged.  Virtual care platforms can drive communication in real-time during the natural points of intersection across the points of care.