Home Health Care and Re-Hospitalization Reduction


Unfortunately, there are times when a person is required to return to the hospital after a period of time subsequent to being discharged. Through the use of a transitional care management program, the occurrence of re-hospitalizations can be greatly minimized. This is a very important issue, as re-hospitalization may be an indicator of inappropriate patient care, or a patient’s inadequate understanding of the disease management process. It is imperative that home health care agencies understand and execute appropriate process improvement plans to reduce these re-hospitalization rates. This is typically accomplished by better understanding the reasons why patients are re-admitted to the hospital shortly after they are discharged.

The first step in reducing patient re-hospitalization rates is to identify risks factors and patient characteristics with respect to their particular disease types.

Some of the identifiable risk factors include:

  • Recurrent hospitalizations within a 12-month period
  • Recent decline in mental status
  • Frailty indicators (i.e., weight loss, muscle weakness, etc.)
  • History of falling
  • Taking five or more medications


  • Certain diagnosis categories have higher re-hospitalization rates than others and include (in order of significance):
    • Cancer/neoplasm
    • Ulcers
    • Congestive Heart Failure (CHF)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Diabetes

Steps in preventing re-admission of high-risk patients within 30 days of discharge include: timeliness of the initiation of home health care services with multiple home visits during the first couple of weeks after discharge, initiation of the transitional care management program, and consideration of the patient’s overall health status.

Additionally, payer groups have a significant relevance in re-hospitalization rates and are often based on social-economic factors that impact the patient’s health. Besides the patient’s overall well-being, financial considerations are a necessary part of the health care industry. Process improvement plans to reduce re-hospitalization are so important that even Medicare recently implemented monetary penalties, up to 3% of Medicare inpatient revenue, for the 30-day readmission to the hospital for:

  • Acute Myocardial Infarction (AMI)
  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Pneumonia
  • Joint Replacements

These penalties were implemented in an attempt to assure quality of patient care. Aftercare treatment and oversight of these five disease processes should be effectively managed through proper training and education of the patient, thus avoiding complications requiring re-hospitalization.

A Process Improvement Plan is established upon initiation of home care services and development of the transitional care management team when goals and interventions are established. The process improvement plan is very complex and patient-specific. Considerations to address include fall prevention, CHF, COPD, diabetes and stroke, and patients need to be provided with educational materials presenting details of the specific disease processes. The materials should present causes, treatments, required life style modifications, as well as signs and symptoms indicating an exacerbation of the disease. In addition to educational materials, the process improvement plan should mandate frequent and routine interdisciplinary team meetings to discuss the patient’s plan of care and progress toward established goals. Members of an interdisciplinary team include transitional care management physician (or nurse practitioners), registered nurse, physical therapist, occupational therapist, speech therapist, medical social workers, and home health aides.

Patient re-hospitalization reduction can be accomplished through identifying risk factors and implementation of the transitional care management team. These measures, when performed diligently, prove to be an effective tool in assisting the patient in successfully managing their overall health and well-being.



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