Embracing Home Health Remote Monitoring to Reduce Readmissions


May 13, 2024
A female nurse checking in on their male patient who is holding a tablet inside of their home.

Readmission Rates, a Growing Problem

The average hospital readmission rate has grown to 14.5%. Nationally, readmission rates range from 11.2% to 22.3%. Readmissions are even more common among Medicare beneficiaries and Medicaid beneficiaries with disabilities, where historically 20% and 16% of discharged patients, respectively, return within 30 days. The National Institutes of Health estimate that 27% of hospital readmissions are preventable. Over 61% of ED visits are considered non-urgent or less urgent.

Since 41.7% of Medicare patients use post-acute care services after being discharged from the hospital it is no wonder that CMS has turned to home care agencies for help in improving patient outcomes and reducing avoidable costs.  

Starting in 2024, home health agencies also are being held accountable for both hospitalizations and ED visits incurred by patients under the care of the home health agency. Based on their overall performance on all the measures in HHVBP, agencies can earn an extra 5% in revenue or be penalized up to 5%.

A table showing the growing regulatory burden of OASIS-based measures, claims-based measures, and HHCAHPS survey-based measures.

Common Reasons for Home Health Patient Readmissions

The reasons for readmission of home health patients to the hospital can vary, but here are ten common factors:

  1. Medication Management: Issues related to medication adherence, dosage errors, or adverse reactions. Patients may not understand their medications or know how to deal with adverse reactions.
  1. Infection: Wound infections, urinary tract infections, or respiratory infections can develop or worsen after discharge. Patients may have been coached on the signs of infection prior to discharge and again during the intake assessment but between pain and all the activities transitioning from hospital and home they may forget.
  1. Exacerbation of Chronic Conditions: Conditions like heart failure, chronic obstructive pulmonary disease (COPD), or diabetes may worsen without proper management. Low healthcare literacy is a challenge.
  1. Falls and Injuries: Accidents or falls within the home leading to injuries, especially for elderly patients.
  1. Dehydration/Malnutrition: Inadequate fluid intake or poor nutrition can lead to complications. Patients may be reluctant to share challenges feeding themselves out of embarrassment. These challenges are especially concerning for diabetics and patients that need adequate nutrition to heal.
  1. Uncontrolled Symptoms: Symptoms like pain, nausea, or shortness of breath may become unmanageable. These can be scary to the patient, who may not think to reach out to the home health agency for support.
  1. Lack of Follow-up Care: Missed appointments or failure to follow post-discharge care instructions. Assume health literacy may present challenges here as well.
  1. Social Determinants of Health: Issues such as lack of social support, unstable housing, food insecurity, or financial constraints can impact recovery.
  1. Complications from Procedures or Surgeries: Complications arising from recent procedures or surgeries may necessitate readmission.
  1. Lack of Care Coordination: Poor communication between healthcare providers, insufficient discharge planning, or inadequate coordination of care services.
A nurse putting a blood pressure cuff on a elderly woman as apart of her basic home health check-in.

Periodic Visits Are Not Enough

These topics are addressed during scheduled visits, but what if the patient does not recognize the health worker and does not answer the door? What if concerns arise outside of the regularly scheduled visits? What if the patient and caregiver do not recall or do not understand the instructions that staff delivered verbally? What if something happens after hours? Despite the best intentions of the agency, these things happen regularly. How can a home health agency provide more wrap-around support to their patients and prevent avoidable admissions and ED visits?

Digital Engagement is Key

Remote patient monitoring has been discussed to prevent readmissions. There is a place for remote monitoring in select situations, such as a digital scale to track weight gain that typically precedes a worsening cardiac event. Look at the list of common reasons for readmission again. Remote monitoring devices can be difficult to get prior authorization and provide an incomplete solution.  

Think instead about Digital Therapeutic Monitoring and Digital Patient Engagement. What might that look like in your agency?

  1. Send new patient referrals a welcome chatbot to introduce them to the agency and get initial assessments scheduled faster.
  1. Send a series of simple chatbots to reinforce key instructions such as signs of infection, provide simple patient education (including videos) and when and how to reach out to the home health agency.
  1. Enable patients to schedule a virtual visit or initiate a secure chat from your website or by texting a phone number.
  1. Schedule a cadence of friendly check-in chatbots to, for example, screen for signs of infection, and social determinant concerns, and confirm that the patient is taking medications as prescribed. Offer the ability to escalate to a digital or virtual visit with a live agent.
  1. Enable staff to initiate a scheduled or ad hoc video conversation to address questions or changes in patient condition.
  1. To reduce rescheduled appointments, send a chatbot before a scheduled appointment to confirm the day of the appointment, send a picture of the care team member, and remind the patient to secure pets, have a caregiver present, etc.
  1. Send a chatbot after the visit with a brief satisfaction survey to screen for satisfaction and any concerns that the agency needs to address.

These are just a few ways that you can increase patient monitoring and engagement while also increasing the operational efficiency of the care team.

Why QliqSOFT

Value-based care has increased the stakes for agencies to improve patient outcomes and satisfaction. With critical staffing shortages, organizations need to be creative in how they can increase monitoring and support with the resources that they have.  

QliqSOFT’s digital communication platform includes a set of robust capabilities to reach out to patients asynchronously, either individually or with campaign automation at the population level. Our robust no-code tools allow agencies to solve a myriad of both patient and staff communication needs within one integrated solution.

A table showing the five ways qliqsoft can augment workflows with integrated virtual care: chatbots, quick forms, care campaigns, secure texting, and virtual visits.

Our services team will share their expertise working with other organizations like yours while helping you kick off and grow your digital engagement program.  

It is time to take control of your HHVBP performance. QliqSOFT can help.

The Author
Bobbi Weber

Bobbi is a lifelong learner who is passionate about enabling healthcare transformation. She has 20+ years of healthcare experience in care delivery, consulting, healthcare IT, and market strategy.

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