| Description |
Transitions of care from acute to post-acute settings often face inefficiencies and communication breakdowns leading to potential medical errors, avoidable hospital readmissions, and added costs to the healthcare system. A lack of coordination between hospital teams and home health providers can leave patients vulnerable, impacting both their recovery and overall experience. Heal at Home was established to bridge this critical gap. Goal/Aim: By ensuring efficient transitions from acute care to home, this partnership enhances care coordination, improves outcomes, and increases health system efficiency. We envision a future where operations are orchestrated to allow a home health provider to be at the patient's home when they arrive from the hospital. This proactive approach has demonstrated enhanced patient safety, reduced readmissions, and improved overall care outcomes. Actions Taken: Developed in collaboration with Community Nursing Services (CNS), ensures seamless care transitions by fostering transparency and accountability between our academic medical center and CNS. By prioritizing strong communication pathways and care protocols, we improve care coordination and ensure patients receive timely, high-quality support at home. Results: In CY 2024, created/saved 524 bed days, 30 day readmissions and ED visits much lower than traditional home health, exceptional high patient satisfaction rate of 98% willing to recommend Heal at Home to friend or family member, and the creation of admission avoidance model in our ED for cellulitis, pneumonia, and pyelonephritis. We currently have 22 heterogeneous medicine/surgical programs in operation with Heal at Home. Finally, this program uses the home health benefit, therefore it is self-sustaining by utilizing existing reimbursement mechanisms. |
