Reducing ACH ... Hospital Connection

What you need to know about the HHQI National Campaign:

• Currently, more than one in four home health patient episodes will result in a hospitalization.
• The Home Health Quality Improvement National Campaign focuses on patients, and is geared toward delivering the right care at the right time, every time.
• Campaign participants will work to reduce the number of avoidable hospitalizations in the home care setting while improving outcomes and patient satisfaction.

Recommended Best Practices

Medication Management

• Promotes patient/caregiver ability to independently manage medications
• Facilitates medication reconciliation through use of universal medication tool and medication discrepancy tool

Hospital Discharge Planner - Communicate with home health agency any potential barriers with medication managment during transition from hospital to home care.

Hospitalization Risk Assessment

• Determines the hospitalization risk level for each home care patient
• Risk factors: Prior pattern of hospitalizations or emergency room visits, chronic conditions (CHF, Diabetes, COPD), lives alone, confusion, history of falls
• Completed by the home care clinician

Hospital Discharge Planner - Communicate with home health agency if there are concerns that patient is at risk for re-hospitalization during transition from hospital to home care.

Emergency Care Planning

• Educates patients and caregiver on when and how to contact the HHA and when and how to seek emergency assistance
• Promotes patient self-management

Hospital Discharge Planner - Communicate with home health agency any conerns about patient's ability to comply with self-care management during transition from hospital to home care.