Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients

Home Visits: Five Pillars to
Reduce Readmissions and Empower High-Risk Patients

As part of its CMS' Community-based Care Transitions Program demonstration project, the Council on Aging (COA) of Southwestern Ohio has been conducting home visits for Medicare fee-for-service patients at high-risk of readmission to the nine hospitals participating in the program.

The program has reduced readmissions from a baseline readmission rate of 22 percent to between 9 and 12 percent since its inception in March 2012.

During Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, a 45-minute webinar on April 21, 2015 at 1:30 p.m. Eastern, Danielle Amrine, transitional care business manager at the Council on Aging Southwestern Ohio, will share the key features of this home visits program, from how the visit is scheduled, what's assessed during the visit, the touch points that occur after the home visit and how the program has evolved since its launch.

Register for the webinar today or order your training DVD or CD:
http://store.hin.com/product.asp?itemid=5029

Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients

You will learn:

  • The strategic importance of hospital-based health coaches scheduling a home visit at the time of discharge;
  • How the hospital-based coaches stratify patients to determine who receives a home visit and the top five disease states that these coaches target;
  • The fifth pillar that COA added to Eric Coleman's Care Transitions Intervention® and why this was critical to a patient-empowered home visit process for COA;
  • The goals for 30 days post-discharge — how many days post-discharge is the visit conducted, visit expectations and assessment goals for the coaches and what happens after the home visit;
  • What approach COA takes for patients who transition to a nursing home or post-acute facility after a hospital discharge;
  • How COA has addressed documentation and case load challenges and is working toward a disease specific home visit; and
  • The impact the program has had on readmission rates and medication reconciliation.

You can "attend" this program right in your office. It's so convenient! Invite your staff members to participate in the conference. We will send you a login to access the webinar or a DVD or CD-ROM of the conference proceedings once it's available for shipping.

You'll also have the opportunity to have all of your questions answered by Danielle Amrine during the interactive question and answer session. You'll get answers to your questions and challenges on home visits for high-risk patients.

To register for the conference, the on-demand re-broadcast or MP3 download file or order the training DVD or CD-ROM of Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, please visit:
http://store.hin.com/product.asp?itemid=5029

I hope you find it useful.

Cordially,

Melanie Matthews
Executive Vice President
The Healthcare Intelligence Network

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