Improving patient outcomes with better care transitions: The role for home health

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ABSTRACTPatients, particularly the old and frail, are especially vulnerable at the time of hospital discharge. Fragmentation of care, characterized by miscommunications and lack of follow-up, can lead to oversights in diagnosis and management. The frequent result is avoidable rehospitalization. Amedisys, a home health and hospice organization, created and tested a care transitions initiative for its impact on patients’ quality of life and avoidable rehospitalizations. The initiative was carried out in three academic institutions with 12 months of observation. The results suggested reduced hospital readmissions and a critical role for the home health industry in improving patient outcomes and reducing costs.



The US health care system faces many challenges. Quality, cost, access, fragmentation, and misalignment of incentives are only a few. The most pressing dilemma is how this challenged system will handle the demographic wave of aging Americans. Our 21st-century population is living longer with a greater chronic disease burden than its predecessors, and has reasonable expectations of quality care. No setting portrays this challenge more clearly than that of transition: the transfer of a patient and his or her care from the hospital or facility setting to the home. Addressing this challenge requires that we adopt a set of proven effective interventions that can improve quality of care, meet the needs of the patients and families we serve, and lower the staggering economic and social burden of preventable hospital readmissions.

The Medicare system, designed in 1965, has not kept pace with the needs and challenges of the rapidly aging US population. Further, the system is not aligned with today’s—and tomorrow’s—needs. In 1965, average life expectancy for Americans was 70 years; by 2020, that average is predicted to be nearly 80 years.1 In 2000, one in eight Americans, or 12% of the US population, was aged 65 years or older.2 It is expected that by 2030, this group will represent 19% of the population. This means that in 2030, some 72 million Americans will be aged 65 or older—more than twice the number in this age group in 2000.2

The 1965 health care system focused on treating acute disease, but the health care system of the 21st century must effectively manage chronic disease. The burden of chronic disease is especially significant for aging patients, who are likely to be under the care of multiple providers and require multiple medications and ever-higher levels of professional care. The management and sequelae of chronic diseases frequently lead to impaired quality of life as well as significant expense for Medicare.

The discrepancy between our health care system and unmet needs is acutely obvious at the time of hospital discharge. In fact, the Medicare Payment Advisory Commission (MedPAC) has stated that this burden of unmet needs at hospital discharge is primarily driven by hospital admissions and readmissions.3 Thirty-day readmission rates among older Medicare beneficiaries range from 15% to 25%.4–6 Disagreement persists regarding what percentage of hospital readmissions within 30 days might be preventable. A systematic review of 34 studies has reported that, on average, 27% of readmissions were preventable.7

To address the challenge of avoidable readmissions, our home health and hospice care organization, Amedisys, Inc., developed a care transitions initiative designed to improve quality of life, improve patient outcomes, and prevent unnecessary hospital readmissions. This article, which includes an illustrative case study, describes the initiative and the outcomes observed during its first 12 months of testing.


Mrs. Smith is 84 years old and lives alone in her home. She suffers from mild to moderate dementia and heart failure (HF). Mrs. Smith’s daughter is her main caregiver, talking to Mrs. Smith multiple times a day and stopping by Mrs. Smith’s house at least two to three times a week.

Mrs. Smith was admitted to the hospital after her daughter brought her to the emergency department over the weekend because of shortness of breath. This was her third visit to the emergency department within the past year, with each visit resulting in a hospitalization. Because of questions regarding her homebound status, home health was not considered part of the care plan during either of Mrs. Smith’s previous discharges.

Hospitalists made rounds over the weekend and notified Mrs. Smith that she would be released on Tuesday morning; because of her weakness and disorientation, the hospitalist issued an order for home health and a prescription for a new HF medication. Upon hearing the news on Monday of the planned discharge, Mrs. Smith and her daughter selected the home health provider they wished to use and, within the next few hours, a care transitions coordinator (CTC) visited them in the hospital.

The CTC, a registered nurse, talked with Mrs. Smith about her illness, educating her on the impact of diet on her condition and the medications she takes, including the new medication prescribed by the hospitalist. Most importantly, the CTC talked to Mrs. Smith about her personal goals during her recovery. For example, Mrs. Smith loves to visit her granddaughter, where she spends hours at a time watching her great-grandchildren play. Mrs. Smith wants to control her HF so that she can continue these visits that bring her such joy.

Mrs. Smith’s daughter asked the CTC if she would make Mrs. Smith’s primary care physician aware of the change in medication and schedule an appointment within the next week. The CTC did so before Mrs. Smith left the hospital. She also completed a primary care discharge notification, which documented Mrs. Smith’s discharge diagnoses, discharge medications, important test results, and the date of the appointment, and e-faxed it to Mrs. Smith’s primary care physician. The CTC also communicated with the home health nurse who would care for Mrs. Smith following discharge, reviewing her clinical needs as well as her personal goals.

Mrs. Smith’s daughter was present when the home health nurse conducted the admission and in-home assessment. The home health nurse educated both Mrs. Smith and her daughter about foods that might exacerbate HF, reinforcing the education started in the hospital by the CTC. In the course of this conversation, Mrs. Smith’s daughter realized that her mother had been eating popcorn late at night when she could not sleep. The CTC helped both mother and daughter to understand that the salt in her popcorn could have an impact on Mrs. Smith’s illness that would likely result in rehospitalization and an increase in medication dosage; this educational process enhanced the patient’s understanding of her disease and likely reduced the chances of her emergency department–rehospitalization cycle continuing.


The design of the Amedisys care transitions initiative is based on work by Naylor et al8 and Coleman et al,6 who are recognized in the home health industry for their models of intervention at the time of hospital discharge. The Amedisys initiative’s objective is to prevent avoidable readmissions through patient and caregiver health coaching and care coordination, starting in the hospital and continuing through completion of the patient’s home health plan of care. Table 1 compares the essential interventions of the Naylor and Coleman models with those of the Amedisys initiative.

The Amedisys initiative includes these specific interventions:

  • use of a CTC;
  • early engagement of the patient, caregiver, and family with condition-specific coaching;
  • careful medication management; and
  • physician engagement with scheduling and reminders of physician visits early in the transition process.

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Improving outcomes and lowering costs by applying advanced models of in-home care

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