Tips For Successful Transitioning From The Hospital To Home Health Care

During the transition from hospital to home health care, patients face a significant risk of adverse events which may negatively affect patient safety leading to readmission or even worsening of health and death. Events such as falls and missed doses come to mind. Ensuring that the patient’s transition from home to health goes smoothly care is a collective responsibility for the medical staff, the patient and their intended caregiver. Below are some tips that could help to facilitate the process:

  • Proper information– it is important to get information about various aspects regarding the patient’s condition. These include:
    • A detailed listing of diagnosis and all the procedures that were performed. This comes in handy in case the patient has to be readmitted at a different hospital.
    • An accurate guide on diet requirements and restrictions, treatments, post-discharge therapy.
    • A list of key contacts including doctors, pharmacists and home care agency representatives among others. If possible collect their business cards for safe keeping.
    • A realistic assessment of the patient’s outlook- this should include expected recovery time and symptoms of relapses.
    • A list of available community and hospital resources. Ensure you have information on all facilities that can handle the patient’s illness.

It is vital that a high level of communication is maintained between the hospital staff and the patient even after they have been discharged.

  • Caregivers are very important– It is not safe for a patient who has just been discharged to be by themselves at home. When a patient returns home from hospital they tend to have lingering effects such as pain, dizziness and muscle weakness. This makes performing certain tasks difficult and they are especially vulnerable to falls. If you are the one being discharged ensure you have a caregiver. This can be a family member, friend or even a hired professional home care attendant. If you have a loved one coming home, consider getting caregiver training. Learn how to take care of them while they are still in the hospital so that you fit into the role seamlessly. Don’t be afraid to ask hospital staff to demonstrate certain tasks and also ask their realistic expectation of what the future will be like.
  • Medication management– this is one of the most vital aspects of home healthcare. In most cases, once a patient is discharged the medication routine will change leaving room for errors. It is important that you verify medication by brand name before leaving the hospital so that there is no confusion in case you have to buy the medication. Ensure you understand why old medication has been stopped, what new medication does and the kinds of reactions and side effects to expect if any (see also: Medicare Part D Medications).
  • Prepare the patient’s home and acquire the necessary home care equipment– various adaptations will need to be done to various aspects of the home to ensure the patient is as comfortable and as safe as possible. Remove excess clutter to allow easy passage and clear items such as cords and area rugs that increase the risk of falls. You may need to install a ramp in place of stairs to facilitate movement of a wheel chair. You may also need to bring in equipment such as a hospital bed, stethoscope and wheel chair among others.
  • Prepare for additional expenses– it is important to plan for how to raise additional funds required to sustain various aspects of home health care. Running out of money can be very risky since the patient may be unable to acquire required medication and other needs. Some services of home care are covered by medical insurance which may help to ease the financial burden.
  • Timing of the discharge– the patient should be discharged only when the doctor thinks they are ready to go home. Hasty discharging could prove fatal. Some patients insist on being discharged as soon as possible disregarding what is best for them. In such cases it is up to the doctor to be assertive and do what is in the best interest of the patient. In case of early discharge the hospital staff should take a keen interest in the patient’s welfare. They should only be allowed to leave if there is a suitable post discharge place where they can go to and be assured of good care.

Home Health Medication Therapy Management Shows Limited Results

Low-risk Medicare patients entering home health care who received medication therapy management by phone were three times less likely to be hospitalized within the next two months, while those at greater risk saw no benefit, according to a study led by Purdue University.

The study helped determine which patients benefit most from medication therapy management by phone and a way to identify them through a standardized risk score, said Alan Zillich, associate professor of pharmacy practice at Purdue, who led the research.

“Hopefully, this study will help home health care providers target the intervention to those who it will help and improve patient health,” he said. “It also tells us there are some patients for whom medication therapy management by phone doesn’t work and that we need a different strategy to help these patients.”

In medication therapy management a pharmacist evaluates the medications prescribed and how a patient is feeling to identify and resolve issues, including untreated conditions, drug interactions, adverse drug reactions, inappropriate drugs or doses and whether a patient is taking the medications as prescribed.

“We know that medication therapy management (MTM) improves adherence, improves outcomes and improves lives,” said Patrick Dunham, CEO of Curant Health, which provided the medication therapy management interventions. “Reducing hospital admissions for the lowest-risk patients in this study by 86 percent is another powerful proof point for the value of MTM and its capability to simultaneously reduce costs and improve care across the health care continuum.”

As Medicare may add incentives or penalties for home health care providers based on hospitalization rates, studies of medication management models could influence policy, Zillich said.

“Enhancing the quality of care for patients has always been the goal of health care providers, but the growing costs of Medicare and health care in general have put an even brighter spotlight on strategies to improve patient outcomes and reduce unnecessary costs,” he said. “Medication therapy management is considered a valuable tool in this effort, but the best way to deliver it and the patients whom it will most benefit have not been well studied.”

Zillich led a team of researchers who collaborated with the home health care organization Amedisys Inc., and pharmacists from Curant Health (formerly HealthStat Rx), who provided the medication therapy management intervention. A paper detailing the research was published in the journal Health Services Research and is available online. Amedisys Inc. funded the research.

“Just as we hypothesized, post-acute care interventions can make a positive impact on preventing issues the elderly may have with their complicated medication regimes: ultimately resulting in lower admissions,” said Dr. Michael Fleming, chief medical officer for Amedisys.

The study followed 895 patients from 40 Amedisys home health care centers throughout the United States, with 415 receiving the intervention.

The intervention consisted of an initial phone call by a pharmacy technician to verify active medications, a pharmacist-provided medication regimen review and follow-up phone calls from a pharmacist one week later and as needed for 30 days.

The most common types of medication-related errors are identified soon after transitions of care take place and the first days are the most critical, Zillich said.

“Time is of the essence,” he said. “The transition to home-based care – as with any type of transitions in care – is a vulnerable time for patients. It involves a switch in health care providers and sometimes a delay in the handoff of medical records. The patients likely have had significant changes or additions to their medications, and sometimes medication-related problems are just starting to appear.”

The results showed no overall significant difference in the 60-day probability of hospitalization for those who received medication management therapy by phone versus those who did not. However, when the patients were evaluated based on their risk profiles, those in the lowest-risk group who received the service were three times more likely to remain out of the hospital 60 days after entering into home health care.

A patient’s risk of hospitalization was determined through a standard set of nursing assessment items used by all Medicare-certified home health agencies called the “Outcome and Assessment Information Set” or OASIS-C, and the patients were divided into four risk categories.

“Most elderly patients requiring home health care are dealing with multiple chronic conditions and taking multiple medications,” Zillich said. “When we say “low-risk” patients in this context, we are talking about the least sick of a very sick group of patients. I’m not sure why they benefited so much from this intervention while the other groups did not. One theory is that they are better able to receive and retain guidance from a pharmacist over the phone and perhaps face-to-face medication therapy management would better help the higher-risk patients.”

The team plans to further explore intervention models that would be more effective for the higher-risk Medicare patients entering into home health care.