Care programs and partnerships bridge the gap in patient care from the hospital to home. These programs provide comprehensive discharge planning and home follow up, patient education, and most importantly, they identify avoidable health complications early-on, thus curbing the risk of rehospitalizations for high risk patients.⁴ Although this type of care occurs largely outside of the hospital, it starts in the hospital.²
Home healthcare services organizations are adopting quality measures to demonstrate their value proposition -- improved outcomes and lower readmission rates, especially for patients with conditions associated with high-rate readmissions, such as heart failure, COPD, pneumonia and diabetes. Measurements focus on emergency room visits, patient satisfaction, care giver competence, and patient compliance.²
Published research on successful transition care programs to home recommend a set of interventions introduced before and continued after discharge to be effective.² Patient and family engagement, alliance and collaboration among the care team (clinicians, staff and home healthcare organizations)² and patient monitoring are all important in a patient’s transitional care comprehensive plan.
Listed are some examples of evidence-based transition care programs outlining the factors above:²
1. Care Transitions Program
2. State Action on Avoidable Rehospitalizations (STAAR)
3. The Bridge Model - Geriatric Resources for Assessment and Care of Elders (Also known as Project Red)
4. Transitional Care Model
5. Better Outcomes for Older Adults Through Safe Transitions (BOOST)
6. Guided Care
1. Rutherford et al. How-to Guide: Improving Transitions from the Hospital to Community settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013.
2. Labson, M. Innovative and Successful Approaches in Improving Care Transitions From Hospital to Home. Home Health Now Feb 2015;33(2):88-95
3. Alliance for Health Reform. Covering Health Issues 2006-2007: Available at: http:www.allhealth.org/sourcebooktoc.asp?sbid=1.