Home Care Program Engages Clients with Chronic Illness, Reduces Hospital Readmissions

​Hospital readmission of home care clients with selected chronic conditions within 30 days fell from 30% to 13% after two home care agencies implemented a program based on two frameworks, the Transitions in Care Model and Relationship-Based Care, reports an article in the July-August 2015 issue of Home Healthcare Now. The agencies developed the program in partnership with the Home Health Quality Improvement national campaign, an initiative of the Centers for Medicare and Medicaid Services. The program is open to all clients but targets those with heart failure, chronic obstructive pulmonary disease, pneumonia, or diabetes mellitus. The program emphasizes helping clients become engaged in their care and self-manage their chronic illnesses. At their first home care transitional visit, clients are assessed for depression, cognitive impairment, and quality of life. Nurses provide case management services throughout the client's home care episode, planning, implementing, monitoring, and evaluating services.