Timely home visits following patients' discharge from the hospital offer patients tools and support that promote self-management and reduce the likelihood of readmission to the hospital.

In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) Southwestern Ohio, describes her organization's home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

Cognizant that poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and the inappropriate use of hospital emergency and post-acute services, COA developed the home visits intervention, in which field coaches conduct post-discharge visits to patients at home and/or within skilled nursing facilities (SNFs). 

Home visits are a key feature of COA's care transition management initiative, modeled on the evidence-based Eric Coleman Care Transitions Intervention ® (CTI)®. With its focus on community support, the COA care transitions program is designed to help patients access the most appropriate post-acute medical care and home community-based services to avoid more costly nursing home placements when unnecessary.

The COA is a member of the Southwestern Ohio Community Care Transitions Collaborative, the second program in the nation accepted into CMS's Community-Based Care Transitions Program (CCTP). The goals of the CMS CCTP are to: improve transitions of beneficiaries from the inpatient hospital setting to other care settings; improve quality of care; reduce readmissions for high-risk beneficiaries; and document measurable savings to the Medicare program.

This 25-page special report provides the following details:

• The evolution of the COA care transitions intervention and home visits' critical contribution to this initiative;
• The essential fifth pillar COA added to Eric Coleman's CTI model to improve care transitions;
• The roles of hospital and field coaches in care transitions, home visits and SNF interventions;
• Elements of the home visit and SNF interventions, including the all-important medication reconciliation to identify discrepancies, and role-plays to prepare patients for provider questions and concerns;
• The structure of telephonic follow-up after completion of the home and/or SNF visit;
• The necessity of data analytics to shape, evaluate and justify a home visit or care transition program;
• A COA strategy to navigate Medicare reimbursement restrictions and offer some patients a follow-up home visit following their SNF visit;
• Future plans for tailoring home visits and the SNF experience to the big five chronic diseases—pneumonia, diabetes, multiple chronic conditions, chronic obstructive pulmonary disorder and congestive heart failure—as well as behavioral health;

In an expanded question-and-answer section, Ms. Amrine provides a host of details on the tools and hallmarks of the program, including coach skill sets, coping with patient pushback, coach-home visit ratios, and much more.

Table of Contents

• Home Visits: 5 Pillars to Reduce Readmissions and Empower High-Risk Patients
  • Southwest Ohio Care Transitions Collaborative Goals
  • Using the Eric Coleman Care Transitions Intervention (CTI)® Model
  • Hospital and Field Coaches
  • Expanding the 4 Pillars of the Coleman Model
  • Medication Reconciliation During Home Visits
  • Home Visit and SNF Visit Interventions
  • Telephonic Follow-Up
  • Future Plans
• Q&A: Ask the Experts
  • Home Visit Teams
  • Telehealth and Remote Monitoring in Care Transitions
  • Addressing Communications Challenges
  • Using the LACE Readmissions Tool
  • Project RED for Medication Reconciliation
  • Scripts for Follow-Up Calls
  • Coach-Patient Ratios
  • Duration of Post-Discharge Follow-Up
  • Duration of Home Visits
  • Coach Skill Sets
  • Palliative Care
  • Collaborating on Medication Reconciliation
  • Coach-Physician Care Coordination
  • PHR-EMR Integration
  • Caregiver Communication
  • Tracking System for Medication Reconciliation
  • Patient Resistance to Home Visits
  • Interacting with SNF Staff
  • Relationships with Community Services
  • Psychosocial Barriers to Self-Management
  • Behavioral Health Pilot
  • Community-Based Internships
  • Advice for New Home Visit Programs
• Glossary
• For More Information
• About the Contributor