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Fixing The Hospital-To-Home Health Care Transition

July 2, 2024

Published by Home Health Care News
By Andrew Donlan

The transition between hospital discharge and home health care is often fraught with issues. Unfortunately, it also happens to be one of the most crucial parts of a patient’s care journey.

With more sick and complex patients coming into home health care than ever, a swift start of home health care is also arguably more important than ever.

“When I’m talking about acuity creep, I’m thinking about how much need do the patients in our care models require?” Michael Johnson, president of home health and hospice at Bayada Home Health Care, told Home Health Care News earlier this year. “It’s not just medical needs, either — there’s a social need as well. We’ve seen a definite increase in the needs of our patients.”

When patients are discharged from the hospital with high needs, only to be left alone at home without care for a period of time, all parties suffer. The patient especially, but also the home health care agency, which starts behind the eight ball. And also the hospital, which is more likely to see that patient again in short order.

The Discharge to Assess (D2A) Model was a response to this issue in England. The Supporting Older Adults at Risk (SOAR) program, following a similar framework to D2A, was also recently established in the U.S.

A study of SOAR’s results within a pilot program in Pennsylvania was recently published in the Journal for Healthcare Quality.

“On hospital discharge and transition to the next level of care, older adults continue to face risks such as miscommunication, gaps in care and medication-related issues,” the researchers wrote. “Transitional care models are designed to address these challenges with the primary aim of preventing readmissions.”

The goal of SOAR is to start a soon-to-be home health patient’s plan of care in the hospital, and not in the home.

SOAR was conducted at a “large urban academic medical center and an associated home health agency from October 2019 to March 2020.” Patients aged 70 and older – who qualified for home health services – were included in the pilot program and subsequent study.

The Research Institute for Home Care (RIHC) helped support the research.

“The goal of the SOAR program is to provide a high-quality, nurse-led replicable transition of care framework from hospital to home. SOAR unfolds in three phases, Prepare (hospital), Transition (hospital to home), and Support (care in the home),” RIHC’s coinciding research brief read.

Ultimately, patients involved in the SOAR program saw much better results from their plans of care.

SOAR patients were more likely to be discharged before noon, but also more likely to receive home health services quickly. Specifically, SOAR patients received home health care within 6.3 hours compared to the control group, which received care within 49.3 hours, on average.

“SOAR participants were also more likely to use the hospital-based outpatient pharmacy to obtain medications before discharge,” the study read. “Patients in the SOAR group experienced a shorter length of stay by more than one full day and fewer emergency department visits. Forty-two percent achieved their patient-centered goals, and 36% were progressing toward goal achievement. Goals included spending time with family, improving physical activity, improving quality of life and participating in personal hobbies.”

The SOAR program puts more fuel behind the emphasis on timely home health care, but also on health system and home health agency relationships.

During a time when home health payment is being cut – and home health access is dwindling as a result – the positive and clear results of models like SOAR should be telling for policymakers.

When there is reduced access to home health services in a given area, discharged patients have a harder time receiving services. An all-time high referral rejection rate from agencies means that patient cases may be rejected by multiple providers before ultimately finding care. That can also increase the time between discharge and start of care.

Jennifer Schiller, the executive director of RIHC, sees the SOAR program as similar to the Choose Home Act, which was introduced in 2021.

“It really flips the discharge and starts the initiation of care at the hospital, instead of the home,” Schiller told HHCN. “It does mirror, in some ways, the Choose Home Act. It’s a really interesting model, and it’s really important to look at how to bridge those gaps in care transitions.”

That preparation phase starts in the hospital, which puts the patient, health system and provider on the same page from the get-go. It also takes into account patient preferences and patient needs before care is transitioned.

As the U.S. population begins to skew older, care coordination woes will exacerbate. Researchers believe that the SOAR program – and better interoperability between home health providers and hospitals, in general – represents “synthesis and practical translations of multiple discrete components of geriatric evidence-based care.”

“There are obvious gaps, because of payment issues, because of how referrals occur,” Schiller said. “It’s really important, now more than ever, to find new ways to address those gaps, so that you don’t have patients waiting 36 to 48 hours for an initiation of care. There needs to be programs that identify the potential risks before patients are discharged home to avoid rehospitalizations.”

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