Project 2.b.viii Hospital-Home Care Collaboration Solutions.
Alliance staff contact: Nora Baratto | 518.701.2198
Objective: Implementation of INTERACT-like program in the home care setting to reduce risk of re-hospitalizations for high-risk patients.
Project Description: Many patients who previously were transferred to skilled nursing facilities (SNFs) are now being discharged to less restrictive alternative locations, primarily home-based settings. Aside from the many benefits of returning to a known and personal environment, there are the risks of potential noncompliance to discharge regimens, missed provider appointments, and less frequent observation of an at-risk person by medical staff. This project will put services in place to address these risks by matching services with transition care management. Services are expected to last more than 30 days.
Definition of Engaged Patients: The number of participating patients who avoided home care to hospital transfer, attributable to INTERACT-like principles, as established within the project requirements.
- Assemble Rapid Response Teams (hospital/home care) to facilitate patient discharge to home and assure needed home care services are in place, including, if appropriate, hospice.
- Ensure home care staff have knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence- based medicine and chronic care management.
- Develop care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer.
- Educate all staff on care pathways and INTERACT-like principles.
- Develop Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care.
- Create coaching program to facilitate and support implementation.
- Educate patient and family/caretakers, to facilitate participation in planning of care.
- Integrate primary care, behavioral health, pharmacy, and other services into the model in order to enhance coordination of care and medication management.
- Utilize telehealth/telemedicine to enhance hospital-home care collaborations.
- Utilize interoperable electronic health records (EHRs) to enhance communication and avoid medication errors and/or duplicative services.
- Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions.
- Use EHRs and other technical platforms to track all patients engaged in the project.