In recent years, many hospitals have worked with home health and hospice companies to manage patients after they are discharged, helping cut down on readmissions and the costs related to them.
For example, the Cleveland Clinic partnered with Kindred Healthcare, a national post-acute service provider with a home healthcare agency, to serve its post-acute care patients. The partnership includes condition-specific care management programs such as Heart Care to Home to promote successful transitions home after patients are discharged from the hospital and then from a skilled nursing facility.
Once patients transition to their home and enter into the Heart Care to Home program, telemonitoring devices collect their health measures such as blood pressure, heart rate, blood oxygen level, weight and other vital information—all with the aim of reducing the risk of readmission to the hospital.
“Identifying and referring patients to a home health, palliative care or hospice provider post hospital discharge is showing great promise and provides a data platform to track readmission rates even when compared to skilled nursing facility or long-term care placement,” said Sheila Cullen, manager of clinical services for Home Healthcare Solutions, a Cardinal Health company that provides products and services to patients and clinicians in home health and hospice care settings. “We are seeing a trend in using standard system electronic health/medical records to create visibility, improve care coordination, and monitor patients at risk for rehospitalization.”