Right At Home Provides Care Transition Support

Last week I attended a Right at Home conference, and one of the major topics aligns with the government’s recent health care bill. The topic was “care transitions programs” and how they can reduce hospital readmission rates.

On a human level, the thought of someone being readmitted to the hospital very soon after an operation is appalling, but according the the Department of Health and Human Services, one in five patients, after leaving the hospital, will be readmitted within 30 days. Up to 76% of these readmissions may be preventable, says the Medicare Payment Advisory Commission, and the average cost per preventable readmission to Medicare is $7,200.

How are these readmissions preventable? By using Care Transitions Programs. The term “care transitions” refers to the location changes that patients make between health care practitioners and settings during the course of a chronic or acute illness, and how their condition and care levels can vary during these changes. These changes can happen frequently during an unexpected worsening of a patient’s condition, say with a stroke after an outpatient surgery. The patient could go from a Primary Care Specialist (PCP) in the outpatient setting, then to the emergency room, then perhaps to a skilled nursing facility before being released to their home with nursing care.

Now with the federal government looking to save $26 billion in the coming years by encouraging hospitals to lower their preventable readmission rates, hospitals will have extra impetus to develop solutions within their community. Especially since their performance in reducing these preventable readmission rates will start to affect how much Medicare will pay out.

Care Transitions programs are encouraging hospitals to begin the care coordination process much sooner than traditionally done in the past—ideally, when the patient is first admitted to the hospital. Improving care coordination for patients between settings has proven successful in lessening the likelihood of a patient returning for a related readmission. A Care Transitions Intervention Model developed by Dr. Eric Coleman in Colorado has helped hospitals reduce readmission rates by a staggering 35-50%, with annual costs significantly reduced.

This is the area where hospitals are realizing that in-home care providers like Right at Home can help. Hospitals have long seen the connection between readmission and a lack of home health settings, but have not done enough to solve the absence of services after discharge—even something as simple as companion care. Right at Home is the missing link for this type of alternative, or “non-medical,” care, especially when it comes to a lack of a support structure for patients leaving the hospital. A successful transition occurs when a discharged patient has a caregiver that they can rely on, especially in two key areas: preventing medication errors and consistent follow up with the primary care provider.

Medication errors account for many preventable readmissions, and in fact, it’s estimated that 60% of medication errors occur around times of patient transition. A trained caregiver can remind a patient of their medication schedule and even help them remember questions they have for the doctor when they are at their next appointment. More importantly, the caregiver can make sure they make that scheduled follow-up appointment after a surgery, which can prevent readmission. Many patients forget the scheduled appointment or worse, cannot drive themselves and can’t find someone to take them.

Right at Home Central Orange County can help with a variety of situations, post surgery or otherwise, from sitter services in a hospital or nursing facility to support following a stroke or during dementia or Alzheimer’s. We also provide respite care for a family caregiver, which can be useful especially after a major surgery when there’s more responsibility.

For advice and consultation on this or any related topics, please feel free to contact me, Karen Fazio, at Right At Home Central Orange County by calling (714) 730-2647 or via email at rahirvine@att.net.

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