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The Future of Connected Home Health Care

The effects of COVID-19, the industry’s embrace of telemedicine and the diverse healthcare needs of a rapidly aging population have caused home health care to grow faster in recent years than any other healthcare setting. At the same time, the industry-wide transition to value-based care has shifted hospitals’ focus to quality of care metrics including the patient experience, clinical process of care measures, efficiency outcomes and how well they close gaps in care during patient transitions.

However, rates of hospital readmissions continues to be an issue. The truth is that hospital readmissions can be avoided by identifying the key drivers – lack of primary care follow up, insufficient care coordination and poor patient compliance – and using tools to solve for them. The home health care clinician is vital in mitigating these factors throughout the patient’s transition and during the home health period of care. Data shows that effective home health care can reduce the likelihood of hospital readmission by as much as 25%.

The Gaps in Home Health Care & How to Close Them

There are three major challenges that healthcare providers face when achieving harmonious transitions of care:

  • Data Exchange & Transitions of Care: Closing the data exchange gap between a hospital or skilled nursing facility (SNF) and home health care is critical. Still, our data shows that 36% of acute care providers were using manual-only strategies to coordinate patient transitions with the long-term and post-acute care (LTPAC) community in 2019. The same percentage reported not tracking patients after they transferred to post-acute care.

This inevitably omits patient information that is essential to a smooth transition, such measurement and observations, location, patient status and advanced planning information, as well as patient medication, diagnosis, allergy and demographic information. With home health care on the rise, providers must implement the necessary tools and systems that enable coordination and the seamless exchange of data between all partners along the care continuum.

  • Patient Engagement & Compliance: Outcomes-driven care necessitates a delivery model that encourages patient engagement and compliance, and the home health care clinician is integral in facilitating both. Empowering patients to be involved in their own care plan motivates them to adhere to it.

Achieving patient engagement also requires a commitment to progress along a four-step continuum: taking a role in self-management, building knowledge and confidence, taking action and maintaining behaviors agreed upon with the caregiver.

Finally, patient engagement should incorporate medication reconciliation and management, which is one of the most common factors contributing to hospital readmissions.

  • Referrals Management: Referrals tend to result in lost information and gaps in care due to patient leakage. To mitigate this, providers must be in a position to orchestrate and navigate the flow of patients through the entire care continuum.

A strong referral management system not only secures the growth and financial health of home health agencies, but also enables them to have immediate access to important data about the patient including demographics, medications, diagnoses and allergies. This allows agencies to staff the clinician skill set appropriately and seamlessly bridge gaps in care.  

Use Digital Tools to Reduce Readmissions

To avoid gaps in care that come along with exchange of data, patient leakage and patient compliance, healthcare organizations must have access to digital tools that allow them to share data and collaborate seamlessly with other caregivers.

The PointClickCare Home Health Care platform transitions patient referrals through an integrated enterprise platform that digitally captures patient data at intake, at the point of care and across care settings, enabling caregivers to visualize patient insights, reduce manual errors and prevent delays in care plan follow-through. The end-to-end platform facilitates enhanced collaboration with providers across the continuum to improve patient care and outcomes. Notably, it simplifies medication management through a search functionality that allows clinicians to research, visualize and identify drugs based on manufacturer imprints, colors and shape.

A holistic view of patient progress, performance, care schedules, case management and clear goals for staff empower caregivers to deliver the highest possible level of care and improve outcomes for at-home patients.

Check out our recent eBook, where we dive in deeper on how to efficiently manage care transitions.


March 10, 2021