PARTNERING WITH HOME HEALTH AGENCIES
Preparing patients and caregivers is only one part of a safe and effective transition. During the critical transition time, clear communication must ALSO occur with post-acute care providers. And family caregivers are most in need of an ideal transfer when the patient is transitioning to home -- where caregivers can quickly become overwhelmed and home health professionals may arrive the day of discharge (or soon after) with inadequate information about the diagnosis, medications, equipment needs or even the name of the referring physician.
In some cases, patients have not answered the door because they were unaware that home care had been ordered, or home health professionals found themselves knocking on the door to an empty house, unaware that the patient was recovering at the home of a family member. These situations put patients at risk of readmission and can cause lingering anger and frustration.
WHAT HOSPITALS CAN DO TO ENHANCE THE TRANSITION TO HOME HEALTH CARE
When the Illinois Health and Hospital Association and the Illinois HomeCare and Hospice Council presented a joint discharge webinar to their members, the following actions were identified as key to a successful transition.
- Provide thorough hand-off communication/transition of care (H&P, Med list, dc instructions, correct physician)
- Provide complete, accurate discharge instructions (preferably 24 hours or more in advance)
- Set appropriate expectations with the patient regarding home care services and caregiver responsibilities
- Assure (to the best of your ability) that the patient is going to the appropriate level of care
- Be realistic when describing patient needs upon referral (for example, if the patient has required 2 nurses to perform wound care inpatient, they will likely require the same at home)
- Be realistic about whether the patient is stable and strong enough to be transferred home. Sometimes returning home just isn’t possible.
- Understand that attempting to transfer to hospice home care in the last hours may pull the family from the bedside at a critical time, without a discernable benefit. Hospice professionals can support an actively dying patient and family at the bedside without the transfer distraction. Of course, when given time, Hospice can bring together medical care, pain management and emotional and spiritual support at home for not only patients but their families.
- Closing the loop (Engage in post-discharge communication with the family caregiver and the home health agency.)
The Illinois HomeCare and Hospice Council’s Best Practices Committee has identified the following critical elements required for a smooth transition to home care services:
- Projected discharge date and insurance information for preauthorization and verification
- Home address in which care will be provided.
- Patient and Caregiver contact information.
- Name/contact for referring physician and physicians who will be managing the patient’s care at home/signing the home plan of treatment.
- Order for services including disciplines (Visiting Nurse, Physical/Speech/ Occupational Therapy, Home Health Aide, Social Work), labs, treatments (wound care, tracheostomy care, catheter care, etc.), diet, activity, etc.
- Completed Face to Face evaluation documented in the medical record and signed by the referring physician.
- Diagnoses/surgical procedures/treatments/etc.
- Psychosocial elements that may impact care provided at home such as environmental concerns, pets, family issues, behaviors of patient/caregiver, etc.
- Date of next physician appointments/ other medical appointments
- Patient Centered Goals
- Correct Medication list
- Medical equipment needs (crutches, cane, walker, wheel-chair, oxygen, hospital bed, etc.)
- Is the patient aware of home health referral?
Advance notice is always important, particularly if the patient is being discharged on a Friday, since weekends are a challenging time to begin service. When the discharge is done at the last minute, even the most committed discharge teams can make mistakes, forget to capture important information, or leave the patient, caregiver and home health provider inadequately prepared.