Home Health Improves Readmission Rate

March 26, 2014


The Penn Highlands Clearfield Hospital Home Health department has reduced its publicly reported hospitalization rates to below the state and national rates.

In the most recent Home Health Compare report on the Medicare.gov Web site, the agency’s acute care hospitalization rate is 15 percent compared to the state and national rates of 17 percent.

 “Our agency’s primary mission is to help patients stay in their homes. Every hospitalization that occurs adversely affects their quality of life,” states Karen Warfield RN, home care director. “With Medicare now penalizing hospitals for patients who are readmitted with diagnoses of heart failure, myocardial infarction and pneumonia, home health agencies can also play an important role in avoiding costly readmissions.”

Penn Highlands Clearfield Hospital’s quality improvement team includes the following disciplines: nursing, physical therapy, occupational therapy, home health aide, systems/technology administrator and social worker. The agency’s multidisciplinary approach to reducing readmissions was a key to its success.

Using the PDSA (plan, do, study, act) approach to identifying why patients were being readmitted, the team first identified barriers, then brainstormed ways to prevent readmissions.

Utilizing tools from the National Home Health Quality Improvement initiative, the team decided to incorporate a patient self-assessment questionnaire into its best practices. This questionnaire helps patients identify reasons why they may be readmitted.

Engaging the patient and family and providing them with the knowledge of what may precipitate a hospitalization is key to helping them identify early signs and symptoms to report.

The “Zone Tools” are provided to each patient as well, Warfield said. These tools are specific for certain diagnoses such as chronic obstructive pulmonary disease and heart failure and are color coded green, yellow and red. If the patient’s symptoms are in the green zone, they are “all clear”; in the yellow zone, they indicate “caution”; in the red zone, they are a “medical alert”. Patients are also given a poster stating “Call Me First” and instructed each visit in signs and symptoms requiring a call to the home health clinician. All home health staff received education on the use of the best practice tools and began utilizing them with their patients.

“By preventing avoidable hospitalizations, we are improving the quality of life for our clients. Each hospitalization results in a decrease in functional ability, and takes longer for clients to reach their pre-hospital level of independence. All of our home care clinicians are to be commended for their commitment to providing the highest quality of care for their patients,” stated Warfield.

Each November, the National Association for Home Care and Hospice celebrates National Home Care Month, National Hospice Month and Home Care Aide Week to honor caregiving heroes who make a difference in the lives of patients and the families they serve.

Penn Highlands Clearfield Hospital is proud to celebrate the work of its home health and hospice agencies during the national observances.

Penn Highlands Clearfield Hospital Home Health is a Medicare certified agency and has been providing services in Penn Highlands Clearfield County and parts of Centre, Jefferson, Cambria and Indiana counties since 1969.