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In the spring of 2008, our research team partnered with eight home health agencies to review unplanned hospitals among home care patients, and to identify the causes of those hospitalizations determined to be preventable. We reviewed treatment records, interviewed home health staff, and conducted a structured review of agency training and orientation methods. We found that approximately 30% of the hospitalizations reviewed were preventable. More than 80% of these preventable hospitalizations resulted from a narrow range of specific and identifiable causes that are within the control of home health agencies. In the fall of 2008, the Agency for Healthcare Research and Quality provided us with funding to develop and evaluate a performance improvement program that home health agencies can use to reduce unplanned hospitalizations. We are offering, at no cost, the opportunity to participate in pilot testing this program to all Medicare-certified home health agencies.

The Keeping Patients at Home Performance Improvement Program. We have designed this program to help home health agencies address the most important causes of preventable hospitalizations. Practical self-guided materials draw upon recognized professional practice standards and Medicare coverage guidelines. The program will include the following modules:

• Comprehensive care planning (currently available) – This module is designed to address the most common cause of preventable hospitalizations that we observed: narrowly focused scope of skilled services in patients with complex care needs and chronic conditions.
• Patient assessment (fall, 2009) – The challenges of accurate patient assessment and OASIS data reporting have long been recognized. Associated problems impact patient care and the financial viability of home health agencies. This module will highlight common issues and improvement strategies.
• Patient monitoring and responding to changes in conditions (fall, 2009) – Delayed recognition of changes in patient status and/or communication failures are important contributors to preventable hospitalizations. This module will support agencies in establishing effective and reliable patient monitoring and communication practices.

Program Participation. While participation is limited, there is no charge for home health agencies to participate in the program or to use materials. For evaluation purposes, participating agencies will be asked to register through a confidential web-based system and provide feedback on program materials.

Questions? Please call or write to Cher Edmonds, Keeping Patients at Home study coordinator at 801-892-6638 or cedmonds@healthinsight.org.

Acknowledgement. This project was supported by grant number R18HS017903 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.