Home health agencies are now measured on how often they keep patients out of the hospital during care and for 31 days post-discharge. The Potentially Preventable Hospitalization (PPH) measure is a claims-based measure that monitors hospitalizations (including observation status) during the home health stay. The Discharge to Community Post-Acute Care measure assesses the percentage of patients who remain in the community for 31 days without a hospitalization or long-term care hospital stay.
Agencies can impact these measures through strong case management, training and education, encouraging patients and caregivers to call the agency when changes occur, leveraging urgent care, medication management and implementing additional “touch points”. Agencies may choose to incorporate additional touch points after discharge to support patients when changes occur, which may require obtaining orders and readmitting to home health.
Provider Insights has provided a script for post-discharge check-in calls to assist in identifying risks after discharge. Click here to view the script.