Home Health has always focused on Coordination of Care or communication between disciplines, therapy, aide and nursing to provide the best possible care. In fact it is mandated by the State and we are actually surveyed by Public Health to ensure we are doing this.

Now, Medicare has gotten on board. They are actually penalizing hospitals financially if a patient has a “rehospitalization” for the same diagnosis within a certain time period. Some time this is not preventable, but many times it is, especially by an order for Home Health to follow a patient home when being discharged from a Nursing Home or Hospital.

That is why building strong relationships with great communication has always been a number one priority for Spoon River Home Health.

The transition from facility to home is started by either an actual visit that we do to the facility (you two know about this!) or detailed phone

communications.

Why should home health be ordered to reduce rehospitalization?

1. Medication Reconciliation.

Most rehospitalization re occur with in 72 hours of discharge. One of the main reason is because medications are not taken correctly, new medications are not filled, previous medications are not stopped correctly, duplicate medication therapy (a patient may get a new prescription for Coumadin, he was already on Warfarin he takes both, this is a very dangerous blood thinner, he is now taking both).  A Home Health referral means a Registered Nurse will review these meds with the patient and the family, ensuring the correct meds are taken and in the home. Often, going to get meds if necessary. SRHHS also supplies a large organized pill box to ensure the medications are set up correctly, then does follow up visit to teach or ensure the patient/family is capable of setting the box up correctly. If not, Spoon River Home Health will find a pharmacy or offers private pay services to set medications up weekly.

2.  Therapy

After a client has been in the hospital, even if just for a few days, the client often finds him self in a weakened or deconditioned state.  With a home health therapy evaluation, the therapist not only observes the home to ensure it is safe, they actually have the client perform their routine activities of daily living. If the person is safe, no further visits are needed. Often, therapy finds that someone many need some adaptive equipment that can make his life easier and safer such as a toilet riser, grab bars, etc.  The therapist will also recommend special walkers or canes, and then work with the client to gain strength.  A weak client coming home alone, into a house that is not specially adapted can lead to a fall which can send a patient immediately back to the hospital.

3. Nursing

After a bout with a sudden illness, pneumonia, Congestive Heart Failure, having a nurse come to the home and assess vital signs can quickly detect a problem that can be reported to the physician, perhaps a medication increase or decrease, that can prevent the exacerbation of illness, which if not caught quickly can send a patient back to the hospital.

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