Hospitalization Job Aid

Introduction

Reducing hospitalizations and re-hospitalizations are a focus across the healthcare continuum. Every post-acute healthcare provider is expected to reduce avoidable hospitalizations. Home Health plays an important role in safely maintaining patients in their place of residence.

60-day Acute Care Hospitalization: when a patient is admitted to an inpatient hospital within 60 days of home health start of care

30-day Re-hospitalization: when a patient is readmitted to any acute hospital facility within 30 days of being discharged from an acute hospital inpatient stay.

Best practices aimed at reducing avoidable hospitalizations include:

• SOC within 24 hours of referral or dc from inpatient facility• Identifying high risk patients and establishing a POC that addresses risk factors• Medication reconciliation ensuring the patient is taking meds safely as ordered • Front-loading the visits for high-risk patients,• Use of Call the Nurse First flyer and education on after hours availability and on-call process • Instructing on the Zone Tools to recognize escalation of symptoms needing action or intervention before a

ER visit or hospitalization occurs• Utilizing Teach Back method for patient education• Facilitating a timely follow up visit with the primary physician

Another key factor is correctly identifying when it is appropriate to complete a Transfer OASIS (TIF).

Importance

Besides the goal of improving patient outcomes, acute care hospitals, Accountable Care Organizations (ACOs), skilled nursing and rehab facilities and other payers all look to home health to reduce hospitalizations.

60 day hospitalization rates are a measure that is included in the home health Value Based Purchasing pilot that began 1/1/2016 affecting Medicare reimbursement for 9 states over a 5 year period.

In addition, 60 day hospitalization rates are one of the 9 measures included in the Quality of Patient Care Star Ratings that reported quarterly on Home Health Compare as of July 2015.

The acute care hospitals receive penalty from the Centers for Medicare and Medicaid Services (CMS) if their (All Cause) 30-day readmissions for diagnoses of heart failure, acute myocardial infarction, pneumonia, COPD, and elective hip and knee replacements are higher than national averages. Those penalties increase annually.

Target Audience

Clinicians, Clinical Managers

Approximate Completion Time

It should take approximately one hour to complete this job aid

P a g e | 1 Hospitalization Job Aid 1-12-16

Hospitalization Job AidObjectives

1) Identify patients at moderate or high risk of re-hospitalization

2) Implement evidence-based practices to reduce hospitalizations

3) Completing a Transfer to an Inpatient Facility Oasis (TIF) only when appropriate

ContentPower Point (double-click to launch)

Pertinent reports and thresholds1. SHP Alert Manager: Clinicians and Clinical Managers should incorporate addressing and managing

SHP alerts into daily workflow for every OASIS time point. Utilization of predictive alerts that identify patients at risk for hospitalization or adverse events can facilitate development of a POC to address risk factors and help prevent unplanned hospitalization.

2. SHP reports to review and analyze hospitalizations:

a. Hospitalization and Emergent Care Report: provides data for overall risks factors, diagnosis, and reasons for actual hospitalizations and emergent care. Allows drill down to patient detail.

b. Rehospitalization Report: Data and analysis of overall 30 day rehospitalization and per penalty diagnosis. Allows drill down to patient detail.

Access via: SHP/Reports/Agencies/Hospitalization/Hospitalization and Emergent Care Report or Rehospitalization Report

3. SBAR communication: Early coordination with the primary physician is effective in establishing open communication and the SBAR facilitates providing early intervention for symptoms.

4. Case Conference: Discussing high risk for hospitalization patients at weekly case conference can bring the clinician’s focus on early interventions.

SummaryReducing avoidable hospitalizations will improve patient outcomes and create value for our organization as a preferred post acute partner.

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