Post-Discharge Home Visits, SNF Visits Halve
Readmissions for High-Risk Population

In an Ohio care transitions management initiative, post-discharge home or SNF visits to Medicare beneficiaries at high risk for readmission have helped to curb rehospitalizations by nearly 50 percent.

As one of CMS' Community-based Care Transitions Program (CCTP) demonstration projects, field coaches for the Council on Aging (COA) of Southwestern Ohio conduct home visits for high-risk Medicare fee-for-service patients in nine partner hospitals, explained Danielle Amrine, the COA's transitional care business manager during an April 2015 webinar, Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, now available for replay.

Danielle Amrine

The COA of Southwestern Ohio completed 10,202 home visits from June 2012 through 2014, Ms. Amrine said. "The national readmission rate is around 21.3 percent. Those patients involved in our CCTP program experienced a readmission rate of 10.48 percent."

Home visits occur within 24 to 72 hours of a patient's discharge from the hospital; SNF visits within 10 days, to allow the patient to settle in at the SNF. For SNF visits, made to the top 10 nursing facilities where patients most often discharged, field coaches utilize the LACE readmissions tool to assess the need for a home visit post-discharge.

The intervention is designed to empower patients of any age and their caregivers to assert a more active role during their care transition.

In case you missed this webinar, you still have a chance to watch this highly-rated program.

Register to view the conference today or order your training DVD or CD:

Here's what one participant said about the program:

The conference provided "pearls of wisdom from a program that's been doing this work for a few years."

You can "attend" this program right in your office and learn the key features of the COA of Southwestern Ohio's care transitions program, how the program is funded, the fifth pillar added to the care transitions intervention, key findings from the program, patient engagement with a personal health record and how the program is evolving.

Itís so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer ó any time of the day or night, whenever convenient for you and your colleagues ó and benefit from the archived recording of the conference, including the Q&A period.

You'll get to listen to the question and answer session to hear more details on the teams that conduct home visits and the teams that visit patients in SNFs; addressing communication challenges between sites of care; specifics on medication reconciliation; scripts for telephone follow-ups; patient visits per day by hospital coaches and home visit coaches and the different skill sets needed for these functions; the average length and a typical format of a home visit; and overcoming patient resistance to home visits.

To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, please visit:

I hope you find it useful.


Melanie Matthews
Executive Vice President
The Healthcare Intelligence Network

P.S. -- You may also be interested in these resources on home visits for high-risk patients: