The emphasis in health care today is on proactive, preventive and personalized care. As pressure to prevent readmissions grows, hospitals must partner with other health care providers (skilled nursing facilities, rehabilitation centers and home health agencies) in a committed and collaborative effort to reduce and/or prevent rehospitalizations.

Photo: Judy Wilson, R.N., B.S.N.

Effective October 1, 2013, hospital readmissions above certain thresholds will be subject to payment penalties. Readmission is defined as admission to an acute care facility that occurs within 30 days of discharge. The initial focus will be on readmissions for congestive heart failure (CHF), acute myocardial infarction and pneumonia.

Reliant Home Health, a San Antonio-based home health agency, has been successful in reducing rehospitalization with specific CHF and chronic obstructive pulmonary disease disease-management programs. According to a 2006 study by Seattle’s Outcome Concept Systems, approximately 41% of patient rehospitalizations occur during the first three weeks following hospital discharge. Additionally, a 2009 study by the Schneider Institutes for Health Policy at Brandeis University found the U.S. national 30-day readmission rate for CHF is 24.5%.

Building an alliance with the physician, hospital and other health care providers is an important component of providing proactive, preventive and personalized care for patients. A May 2009 Avalere Health report supports the conclusion that home healthcare saves more than it costs. Home health interventions for patients with chronic illnesses are associated with lower Medicare spending and reduce patient rehospitalization. These collaborative efforts can help solve the re-hospitalization problem, which translates to a win-win strategy for everyone.

Reliant Home Health’s Successful Readmission Reduction Program

Reliant Home Health’s rehospitalization rate for the period of January through August 2011 has been less than 10%, providing a significant impact for both the patients and the hospitals Reliant serves. The rate has been achieved with the help of the following measures:

  • Comprehensive initial assessment by Reliant clinician and identification of high-risk patients
  • Coordinated clinical hand off from hospital case manager to Reliant clinician
  • Timely notice to primary care physician (PCP) of patient’s condition
  • Patient follow-up with PCP within two weeks or less
  • Front loading nursing and therapy visits, as the initial days and weeks after release from a hospital have the biggest impact on minimizing rehospitalizations
  • Point-of-care technology providing all staff with real-time, constantly updated patient information
  • Patient education with preprogrammed disease-management teaching templates used by field clinicians and mirroring patient-education disease booklets left in patients’ homes
  • Accurate patient weights via confirmation that a scale is available and that the patient is educated to properly measure weights
  • Detailed medication review with the patient along with provision of easy-to-use medication pill boxes with large print for easy recognition to increase medication compliance
  • Zone instruction using red, yellow and green color-coding system for patient symptom management and appropriate first response to symptom exacerbations
  • Results tracking via bi-monthly rehospitalization meetings

Judy Wilson, R.N., B.S.N., is Executive Vice President of Business Development at Reliant Home Health. For additional information, please call (210) 558‑9606 or visit Reliant Home Health’s website at

MD News November 2011, San Antonio