Improved utilization of home health services
One challenge the coalition faced was the underutilization of and coordination of care with home health providers. To address this, home health professionals began joining daily department team meetings where clinicians identify potential patients who could qualify for home health services and assess those patients to see if they are eligible.
Results: Approximately 86 percent of patients were screened using the new discharge process, leading to a 36 percent increase in home health assignments and support compared to 2015.
Scheduled post-discharge follow-up appointments
Prior to the coalition, 80 percent of high-risk patients were discharged without appointments being made. New processes were put in place for hospital unit clerks to schedule provider follow-up appointments for patients prior to hospital discharge. Additionally, paramedics get a referral from a transition of care nurse and come to the hospital to visit a patient prior to discharge. The paramedics then visit the patient in his or her home 48-hours post-discharge, conducting medication reconciliation and safety checks and answering questions about discharge instructions, including any follow-up appointments. The paramedics will reschedule follow-up appointments, if needed, to ensure the patient can go. Paramedics also screen patients to assess potential need for home health services.
Results: All high-risk patients are discharged with appointments, and to date, 87 percent of follow-up appointments have been kept, as scheduled.
Coordinated home health services for those without a primary care doctor
It was determined that 15 percent of patients who qualified for home healthcare did not receive services due to lack of a primary care physician. Havasu Regional established a "no doc" list in coordination with an emergency department case manager for those patients.
Results: Since June, 10 patients on the "no doc" list received needed home health services.
Through the efforts of the paramedicine program, coupled with the community coalition, readmission rates at Havasu Regional Medical Center have been reduced to less than seven percent.