Enhancing Transitions of Care: The Heal at Home Program

Aim: The aim of the Heal at Home program is to optimize the transition of patients from the hospital to home, ensuring a standardized discharge process and connecting patients with appropriate home health resources to ensure a successful recovery journey. Actions: The steps taken in our standardized program development process to achieve our success included the following: a dedicated multidisciplinary home health team that exclusively cares for our patients to yield trust and consistency, co-developed nursing and therapy care protocols that allow the home care team to practice at the top of their licensure, hospital supported training and skills pass off for the home care team, defined quality measures, bi-directional accountability for the care, and safety of our patients. Results: Heal at Home has demonstrated significant positive outcomes, benefiting both patients and the health system. For the 370 patients that have participated, we reduced their length of stay by an average of 17 hours per patient, a 30-day readmission rate of 6% compared to 17% for all other home health discharges. Additionally, an exceptional patient satisfaction with the Heal at Home program, 96% of patients responding they were "likely" or "very likely" to refer someone. Furthermore, in 2023, we saved 161 bed days, enhancing bed capacity and throughput at UUHC.