Home Health Providers Can Reduce Readmissions by Offering In-Home Coaching

Monday, November 06, 2017




One of the primary goals for Centers for Medicare & Medicaid Services (CMS) — and consequently, home health agencies and hospitals – is a reduction in the number of hospital readmissions. Although overall readmission rates have dropped in 49 of 50 states since 2010, 30-day readmission rates are still higher than CMS and providers would like them to be. As hospitals are penalized for unplanned readmissions, finding ways to keep discharged patients from coming back to the hospital within 30 days is a major priority. 

Home health services play a significant role in this effort. Client home health care is proven to help lower readmission rates, as it helps ensure that patients are following their discharge instructions, including taking medication and going to their follow up appointments. Despite the benefits of home health, though, there are certain risk factors that increase the likelihood of a patient returning to the hospital. Among them? Comorbidities including diabetes, chronic lung disease, heart disease, cancer, and pneumonia. 

While having a comorbid condition isn’t the only factor that contributes to hospital readmissions (age, race, sex, and socio-economic factors also contribute to high risk) it is one that home health can make a measurable difference in reducing. Several pilot programs have introduced the idea of home health workers as health coaches, proving in-home coaching services to encourage patients to take better care of themselves and better manage their chronic conditions, thus increasing the chances of preventing hospital readmissions. 

In-Home Health Coaching: What Is It?

In the simplest terms, health coaching means giving patients the information, skills, and tools that they need to be active participants in their own health and reach certain goals. Usually, those goals are self-defined; i.e., wanting to attend an event or even just walk to the mailbox unassisted. However, in some cases, the goals may be determined by a provider, such as getting blood pressure under control or reducing overall A1C numbers. And in some cases, the goal is simply to avoid a return visit to the emergency room or hospital admission. 

Home health services are already well positioned to offer in-home health coaching. Several pilot programs are expanding their role, though, and using home health providers primarily as health coaches for patients who might not otherwise qualify for home health services. For example, in New York, City Health Works, a Harlem-based nonprofit organization that trains workers as health coaches, and Mount Sinai St. Luke’s (MSSL) hospital are collaborating on a program to determine the effect of in-home health coaching on Medicaid-eligible patients with congestive heart failure. 

The program provides two visits per week for 30 days to patients who are at risk for readmission, and focuses on educating patients on diet, exercise, medications, and follow-up care. The home health caregivers train the patients on how to recognize signs that their symptoms are worsening, and evaluates the patients for red flags, and then notifies the hospital if there is an issue. In most cases, problems can be solved with an adjustment to medication, not a visit to the hospital. 

The New York program is just one of several such programs focused on health coaching. Most health coaching programs focus on four distinct pillars: supporting the self-management of a condition, creating a bridge between patients and providers, providing emotional support for patients and helping patients navigate the healthcare system. In short, rather than just leaving the hospital with instructions, patients receive additional support and information that will allow them to comply with those instructions. 

Becoming a Health Coach

Successful health coaching pilots have led to discussions about how to best leverage home health providers to offer these services. Because health coaching is different than simply providing care, home health workers need to be trained in coaching and how to provide the guidance and education that patients need. Specializing in specific conditions can also help your agency provide the coaching and other services that can reduce readmissions. For example, if your agency specializes in working with individuals with heart disease, your coaching strategy can include providing education and services related to heart healthy meal planning, including shopping and food preparation. 

Because medication management is also a significant factor in reducing readmissions — not to mention meeting CMS quality standards — implementing home health solutions to better track and administer medications, while also coaching patients on their prescriptions, can help improve outcomes. In fact, many of the tasks that home health providers are already doing can be rolled into a coaching program, creating a seamless, comprehensive, and high-quality care experience for patients. 

As the emphasis on quality outcomes and reducing readmissions continues to be at the forefront of CMS’ efforts, in-home health coaching is likely to become a more popular option, and another service line for HHAs. If you are considering adding a coaching component to your service list, check out Complia Health’s comprehensive home health software solutions that will allow you to manage all aspects of your business and provide the best possible care for your clients.