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caregiver and senior woman hugging

As value-based makes relationships between home health care agencies and hospitals more important than ever, one home health provider is taking a closer look at how to reduce rehospitalization rates.

To buck this trend, American careQuest follows a series of best practices to manage care at home.

1. Ensure strong clinical oversight

American CareQuest relies on clinical managers to oversee all aspects of a patient’s care, ensuring communication between physicians and health care tam, as well as coordination of all disciplines providing care.

“At the very grassroots level, providers should make sure that  clinical managers are providing very strong oversight, managing the care that the patients receive, and ensuring that there is continuity of care”.

2. Analyze rehospitalizations

Any time a patient does go into the hospital, AMCQ requires a root-cause analysis to be performed to determine why it happened. Important questions to ask “Was there anything we could have done to avoid that rehospitalization?” and “What should we be doing in the future?”

With this data, AMCQ knows how many patient rehospitalizations were avoidable, and can assess specific cases to prevent future unnecessary readmissions.

3. Identify high-risk patients

Home health providers should use internal and external reporting and communication tools to identify patients who are a high risk for rehospitalization. Then, protocols should be developed for that list of high-risk patients, who may require increased levels of communication and monitoring.

Homecare  health care company that provides communication and information exchange between office staff, field staff and physicians. It also uses Strategic Healthcare Programs (SHP)

Many of high-risk patients are sufferers of congestive heart failure and chronic obstructive pulmonary disease (COPD)—so the home health care has recently introduced two new programs aimed at chronic disease management for these conditions.

4. Stabilize first

AMCQ have found that throwing many disciplines into the home during the first couple weeks of care doesn’t work out well, Time needs to be spent stabilizing the resident’s condition before teaching them to be more independent in their care.

“We must make sure that patients are in the right place in terms of their physical condition, their emotional place and their ability to cognitively understand what it is we’re teaching them,” “They’re not going to be able to be independent in their care until we’ve stabilized their condition.”

5. Implement patient care conferences

AMCQ performs patient care conferences—meetings between the clinical manager, a representative from each discipline providing care and sometimes the patient’s physician and representatives from other care disciplines. This group discusses the resident’s care, what has been accomplished, continuing goals and anything new going on.

These conferences happen at least once every 60 days for every home health care patient, and more frequently for patients whose condition is unstable or whose care requirements are very complex.