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Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

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.

In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) 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.

Cognizant that poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and the inappropriate use of hospital emergency and post-acute services, COA developed the home visits intervention, in which field coaches conduct post-discharge visits to patients at home and/or within skilled nursing facilities (SNFs).

Home visits are a key feature of COA's care transition management initiative, modeled on the evidence-based Eric Coleman Care Transitions Intervention ® (CTI)®. With its focus on community support, the COA care transitions program is designed to help patients access the most appropriate post-acute medical care and home community-based services to avoid more costly nursing home placements when unnecessary.

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 (CCTP). 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.

This 25-page special report provides the following details:

The evolution of the COA care transitions intervention and home visits' critical contribution to this initiative;
The essential fifth pillar COA added to Eric Coleman's CTI model to improve care transitions;
The roles of hospital and field coaches in the care transitions, home visits and SNF interventions;
Elements of the home visit and SNF interventions, including the all-important medication reconciliation to identify discrepancies, and role-plays to prepare patients for provider questions and concerns;
The structure of telephonic follow-up after completion of the home and/or SNF visit;
The necessity of data analytics to shape, evaluate and justify a home visit or care transition program;
A COA strategy to navigate Medicare reimbursement restrictions and offer some patients a follow-up home visit following their SNF visit;
Future plans for tailoring home visits and the SNF experience to the big five chronic diseases—pneumonia, diabetes, multiple chronic conditions, chronic obstructive pulmonary disorder and congestive heart failure—as well as behavioral health;

and much more.

In an expanded question-and-answer section, Ms. Amrine provides a host of details on the tools and hallmarks of the program, including coach skill sets, coping with patient pushback, coach-home visit ratios, and much more.


Home Visits: 5 Pillars to Reduce Readmissions and Empower High-Risk Patients
Southwest Ohio Care Transitions Collaborative Goals
Using the Eric Coleman Care Transitions Intervention (CTI)® Model
Hospital and Field Coaches
Expanding the 4 Pillars of the Coleman Model
Medication Reconciliation During Home Visits
Home Visit and SNF Visit Interventions
Telephonic Follow-Up
Future Plans
Q&A: Ask the Experts
Home Visit Teams
Telehealth and Remote Monitoring in Care Transitions
Addressing Communications Challenges
Using the LACE Readmissions Tool
Project RED for Medication Reconciliation
Scripts for Follow-Up Calls
Coach-Patient Ratios
Duration of Post-Discharge Follow-Up
Duration of Home Visits
Coach Skill Sets
Palliative Care
Collaborating on Medication Reconciliation
Coach-Physician Care Coordination
PHR-EMR Integration
Caregiver Communication
Tracking System for Medication Reconciliation
Patient Resistance to Home Visits
Interacting with SNF Staff
Relationships with Community Services
Psychosocial Barriers to Self-Management
Behavioral Health Pilot
Community-Based Internships
Advice for New Home Visit Programs
Glossary
For More Information
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