Ep.17: How Home Care Agencies Can Reduce Hospital Readmissions

Amanda Sternklar (00:09):

Hi everyone. This is Amanda Sternklar, director of marketing here at hcp, and your host of vision, the podcast for leaders and forward thinkers of the care industry. Today, we’ll be discussing Home Care’s role in reducing hospital readmissions. And to do that, I’m joined by Michelle Cohen and Laura Coyle. Michelle has dedicated her career to improving the value of home care across the care continuum. With over 25 years of experience in the post-acute care space, she’s worked with many top regional healthcare and home care facilities in Texas, as well as some of the best known agencies nationwide. Before joining Home Well Care Services in 2016, today, Michelle equips Home Well’s franchise owners with purposeful brand programs and industry leading training to help them differentiate their agencies. Through her innovative leadership and extensive training for franchise owners and support staff, she helped steer home well into a period of unprecedented success.

Amanda Sternklar (01:03):

Since 2019, homo has achieved over 90% unit growth and expanded its footprint into more than 30 new states. Laura is the executive Vice President of Home Well Care Services. She has been a registered nurse for 29 years and has been with Home well for 10 years. She’s also an active member of Women’s Leadership Group Chief and a Care Switch Advisory Board member. Laura is passionate about providing quality care and focuses on company culture, organized processes, and strategic growth. Laura has a team of over 40 administrative staff and 400 caregivers providing over 9,000 hours of service per week in the community. That is incredible. Thank you both for joining us.

Michelle Cone (01:45):

Thank you, Karen. Thank you.

Amanda Sternklar (01:48):

All right. Well, I’m, I’m so excited to have you, and I know that you are both just as passionate about data as we are here at H C P. So when we released the latest benchmarking report, were you surprised to find that only 25% of agencies are tracking readmissions?

Michelle Cone (02:03):

Well, Amanda, thank you again for having us. We really appreciate taking the time to visit with us today. And you are correct. I would say that Laura and I are both very passionate about data and the value of data collection and of data sharing. Was I surprised by that number? Yes and no. All of us discussed a few weeks back during our podcast prep that after performing a look back at the past several years, data collected through the benchmarking study, this number’s not changed really much at all. Maybe a slight percentage point up and down, but it is basically remained flat. So I was not too surprised that it still sits around 25%. But that being said, as we become further distanced from the Covid 19 pandemic, I am surprised that 75% of agencies survey bait are still not fully recognizing the value of this metric. And I think that there is opportunity there. Absolutely.

Amanda Sternklar (02:54):

Totally

Laura Coyle (02:55):

Agree with you, Michelle. And I think, you know, we, we come on these webinars, we listen, you know, to the industry leaders. It’s a buzz. People are talking about it, but I think some people don’t know how to go about it. You know, they don’t know where to start. And so that’s why this call is so great today because we can maybe motivate and recruit some people.

Amanda Sternklar (03:16):

I’m so excited to hear the, the follow up to this one. So since that number’s so low, let’s start really basic. Why do you believe that it’s so critical for us to track readmissions?

Michelle Cone (03:28):

So, you know, at its most basic level, it really allows home care agencies to monitor and promote the quality of care that they provide to their clients with actual quantitative data. Readmissions have been tracked and monitored by c M S for over a decade now. I was working in home Health back when it was first introduced back in 2010, as a way for c m s to not only create structured penalties for hospitals with excessive readmissions, but also to reward and incentivize those providers for effective care coordination and collaboration with post-acute providers across the care continuum. Now, for those of us in home care, you know, we know original Medicare is not a payer for us. And because of that, I feel maybe our industry has not tr traditionally recognized readmissions as something we really needed to measure. But what impacts those within the care continuum and the patients and clients that we serve also impacts us as a non-medical home care provider as well. A d l support companionship to patients who may be at risk are essential to not only reduce readmissions, but also help prevent admissions from happening in the first place.

Amanda Sternklar (04:36):

Absolutely. I know something that we’ve talked about on the podcast in the past, specifically, not just for increasing coordination, but for improving referrals for your agency, is being able to speak the same language as the folks that you’re seeking referrals from. And I feel like readmission rate is, is one of those kind of points that everyone can understand.

Michelle Cone (04:56):

Absolutely. It puts us on a level playing field. I mean, whether you’re, you have a background in inpatient rehab or skilled nursing facilities or home health or hospice, or even physicians and physician groups. You live and buy, die by the numbers and the metrics and the outcomes. You know, you can call them or reach out to them at any given time, and they absolutely know what their quality measures are. They know what their successful discharge rate to community is. They know what their patient si satisfaction is, they know what those readmissions R rates are, and we need to come to the table prepared to discuss that and how we can provide value to those stakeholders that are being held accountable to those quality measures.

Amanda Sternklar (05:31):

Absolutely. So I know that you both have a really unique program that you use to reduce readmissions. Laura, can you walk us through what that looks like?

Laura Coyle (05:41):

Sure, I would love to. So the Go Home well program, it’s one of our signature programs. Basically, in a nutshell, it just, the goal is to keep people home, prevent readmissions, right? We want to ensure that our clients have the support and the resources they need to stay home safely possibly even gain a level of independence that they once had. So what that looks like for Go Home, well, you know, who qualifies. So in order to enter our Go Home well program, a client needs to have been discharged from a hospital, a rehab, skilled nursing facility within the last 30 days. So that’s how they qualify. Next steps are, you know, our registered nurses and you know, us in New Jersey here, we, you know, operate with registered nurses for our, you know, home health aide supervision and, and personal care. If someone out there is in a state where you don’t have a nurse, if it’s a care coordinator, care manager, whatever the, you know, title is, basically that’s this person who is initially going out to see that patient, do initial assessment, gather that information, and, you know, it’s, it’s vital for them to identify some risk factors.

Laura Coyle (07:01):

You know, they are going in at the start of care, looking at the home. Is this a, a safe home environment or this client to live in, you know, a thorough fall risk, but really a good look around the home and, you know, how can they do their ADLs? Are they safe? Do they need any equipment? Another thing they’re looking at is nutrition food in the home. You know, being, since they’ve just been discharged possibly for a long, you know, period of time, is their food in the home and do they have the resources to get food? What is, what is their system in place? Is their family, do they need food shopping, online, grocery delivery? That’s something we can set up for them. Meals on Wheels, you know, so just ensuring proper nutrition is in place. Medications, do they have all prescribed medications? How do they get them medication boxes?

Laura Coyle (07:58):

Our nurses can assist with that. You know, we can have prefilled, you know, packaged meds delivered from pharmac pharmacies. You know, medication compliance is a really important factor to make sure that that’s, you know, in place that if there’s family education with the family of the importance of the medications and timing, making sure that’s all, you know, being done correctly. Our caregivers, of course, can do those medication reminders. Really important for them to report to our nurses or to the office if they’re not taking their meds. Cuz that’s a huge risk, risk factor for, you know, readmissions, noncompliance, physician appointments, you know, upon discharge they’re typically given, you know, a, a phone number contact or if it’s their regular physician, they’re, they’re returning to specialist. Have they made those appointments? Do they need help making the appointment? So getting getting that in place is, you know, another factor we look at right at the start of care.

Laura Coyle (09:01):

Home health, a lot of times upon discharge, you know, there will be home health in place. So whether that’s, you know, skilled nursing, physical therapy, social worker, speech therapists, all different modalities that we work closely with, which is really important factor. You know, as Michelle was saying, you know, speaking their language, making sure that they understand what we do, what’s our scope of practice versus theirs. We’re not overstepping with their nurses or their, you know, their company. We work hand in hand with them. So we have to teach them what, what are we doing here? What is our place, you know, in this home? How can we support you? How can we communicate with you? And really staying in touch, you know, with those, you know, healthcare pro professionals, nurses, you know, nurse to nurse conversations, symptom management, you know, medication compliance, just speaking that language with them is really important.

Laura Coyle (10:07):

You know, our nurse at that visit will write a very specialized care plan based on that diagnosis the patient went into the hospital for, came home with and specific instructions. You know, let’s, for an example, you know, congestive heart failure, c h F, which is a big, you know, risk, risk factor for a lot of our clients. What is that caregiver looking for and what does she need to do? Daily weights reporting, you know, an increase of three pounds, just getting very specific in that care plan of signs to look for and report. And of course, you know, keeping it within their scope. They’re not allowed to assess or diagnose, but yes, they can observe and they can report to us, you know, important changes. So after that care plan is written, you know, the nurse then is following up at least twice a week throughout those 30 days.

Laura Coyle (11:02):

So they enter, go home, well, they stay on go home well for 30 days until, you know, we deem them having succeeded. You know, we call it a, a graduate home. Well go home, well graduate. Mm-Hmm. In that, in that 30 days, our nurses are speaking to the, the client if possible, the family members, the caregiver, minimum of twice a week, making extra visits. You know, we go out at the start of care, but then we really don’t see the patient again. Sometimes 60 days could be 30 days when they’re on go home, well, we are going out more frequently. We would need to have our eyes on the patient, you know, speaking to them nonstop. Teaching is really vital, you know, early reporting of symptoms so that we can intervene and we can jump in and, and have, you know, if we have a mobile, you know, urgent care company in place, which, you know, is one of one of our power partners that we use, we’ve utilized them to come to the client’s home, diagnose a u t I diagnose a, your urinary tract infection, you know, you have fluids if they’re dehydrated.

Laura Coyle (12:13):

So really supporting that client any way possible to stay home, avoid a readmission, and you know, just have quality of life. So we celebrate, you know, we celebrate them once they reached that milestone and they’re graduate. And then of course that’s something we can go back and report that success story to that referral source wherever they came from. And, you know, they enjoy, they enjoy hearing that.

Amanda Sternklar (12:41):

Absolutely. That is such a fantastic and, and robust program. I don’t think there’s anyone out there that, that couldn’t find something to take away from that to improve their own, their, their own ways to reduce readmissions. Something you said really struck me, like not diagnosing not kind of doing anything beyond their scope, but but being able to collect that, that data, I think there’s been an increased understanding that I hope, hope continues among folks who hadn’t been so familiar with, with home care of the value of having somebody who’s in the home and who can collect that data, who can identify any patterns that would lead to potential readmissions.

Laura Coyle (13:24):

Absolutely. And we have some caregivers that are so sharp, they’ve become even just so intuitive and, and they know their clients, they know the difference day to day. And they can just call us up and say, she’s different today. You know, I can’t put my finger on it, but she’s different today. And then it’s up, you know, it’s up to our nurses to then ask more questions, make a visit, make a phone call, and dive in. You know?

Amanda Sternklar (13:50):

Absolutely. I know you shared a few of them already, but what are some of the other key risk factors that you’ve found that that can lead to readmissions?

Laura Coyle (13:58):

So things that we see, you know, as, as some key risk factors. Clients that live alone, you know, that really don’t have like a support system. They may not have family local living locally. So we are the only ones really seeing that patient, seeing them. Hours of service, low hours of service, or another risk factor. I I failed to mention for, you know, another parameter for go home. Well for us, you know, we only take on someone in that program if they have hours of service, like 20 hours and above. Cuz less than that, we’re just really not in there enough to, you know, be given the opportunity to intervene appropriately. So, you know, when we have a client that’s, that needs 24 hour care, but is only bringing us in five, six hours a day, that’s a risk factor. You know, someone who doesn’t have a primary care physician who’s resistant to care, resistant to, you know, an in-home physician that, you know, our hands are tied there.

Laura Coyle (15:00):

That definitely puts them at, at a higher risk. And of course, you know, the, the diagnoses that, you know, the, the congestive heart failure, pneumonia, heart attack, we see orthopedic diagnoses where fractures falls, you know, just orthopedic surgery in general tends to be leave them at a little higher risk. Dementia. Dementia is a high risk factor for us. We do see our population where they end up having falls, they end up just, you know, having that noncompliance that puts them at a higher risk. And, you know, the diagnosis, sometimes diagnosis that people have. It could be, you know, chronic, multiple chronic diagnoses, asthma, diabetes, obesity. You know, there’s just a few things in that nature that really put our, our clients higher risk. And medications too. When someone is on, you know, more than five medications, we have some clients that it’s just pages of list, 20, 20 something different medications, you know, that that in itself is a risk factor. And just the nature of how they came to us. Anyone who’s been in a hospital or a facility in the last 30 days, they’re automatically at, at a higher risk for readmission. Makes sense.

Laura Coyle (16:24):

I’m interested in, in

Michelle Cone (16:26):

What are some of the results

Laura Coyle (16:27):

That you’ve seen since implementing this program? I

Michelle Cone (16:30):

Know that as a brand we’ve seen very successful outcomes and I’m sure Laura can recognize that within her own agency as well. When I look at our Go Home World program success, I wanna look at it in two ways. I wanna look at it through the lens of a client’s perspective, but also through the lens of a payer and provider’s perspective. Clients aren’t really fascinated with data. They just want to age in place. They want to recover in at the, at the home. They, once they discharge from a hospital or from a rehab facility, last thing they wanna do is return to that facility anytime soon. And we know that the statistically the likelihood of that happening for our 65 p population is one in five. We know that this is tremendously high. When we look at it from their perspective, 20% chance of, of at discharge being remit readmitted within 30 days of that discharge back to the hospital or facility is extremely high.

Michelle Cone (17:19):

For all of those risks that Laura just mentioned earlier. We really have to identify an assessment. Is our client at risk? And if so, what can we do to make a positive impact there? For every percentage point that our program supports in terms of driving down that number, that is an actual client, a living, breathing human being, who we are able to keep at home versus then re-entering a facility. Readmissions take a tremendous emotional and physical toll on clients when they become a revolving door in and out of that facility system. I saw that when I was in inpatient rehab and worked in skilled nursing facilities. And that doesn’t even take into account the stress, the time, and the money that their loved ones and families incurred during that time. So that is from a client and family perspective, but some from a provider or payer’s perspective, you know, 62% of all hospital admissions are those 65 and older.

Michelle Cone (18:09):

And speaking about those chronic conditions that Laura just mentioned, 60% of our aging population has at least one chronic condition and 40% or greater have two or more. And the multiple medications, the revolving door, the lack of family support, all of that you add to their risk really adds to that 20% likelihood that they’re going to reenter that facility. This comes at a, a high heavy price tag too at nms estimated cost to Medicare of 26 billion. We hear that all the time. And studies show that 17 billion of that is considered avoidable. So if we take it down to a micro level, each readmission comes at a cost of about 15,000 to $16,000 per stay. And that cost is only rising. Things are not getting cheaper by 2030. All those baby boomers that we’re working with now are going to be over the age of 65, and those oldest boomers are gonna be turning 85, 20, 30 is gonna be here before we know it.

Michelle Cone (19:06):

So we’re really able to prove with data, with both readmission rates and client satisfaction through our partnership with Home Care Pulse, that our program, which involves really intentional collaboration with the client’s, providers, like Laura mentioned, their physician, their home health agency, their medical equipment company, whoever is involved in that healthcare ecosystem that’s providing support to that client, we are able to bring joy and satisfaction to those clients and their families, but we’re also positively impacting the outcomes for those providers and driving down the cost to payers. So across the full continuum and also incorporating our clients and families, it’s a win-win situation for all that are involved.

Amanda Sternklar (19:47):

Absolutely. You’ve covered clients and families. I’m curious, even just anecdotally, do you have any experience or any thoughts on how this has affected your staff who are involved in the program?

Laura Coyle (20:00):

Yeah, absolutely. You know, clients and families, the impact there I think is huge. And you know, just our nurses, I feel like we have such an, an amazing team of nurses that truly care about every single client that they see that we have on service. So just the, the gratification of knowing they prevented a hospitalization, they prevented an ER visit and you know, we’re all, we all have families, we all have loved ones, right? We’ve all been in situations where we’ve sat in an ER all day, we’ve gone through our own personal journeys with sick family members and, you know, and to know how that feels, to know how it feels to sit in that chair, the angst, the stress, the trickle effect of that with your entire family, to know you’ve helped someone prevent that and avoid that is so gratifying. You know, that is, that’s why we’re here, right?

Laura Coyle (21:02):

That’s why we’re doing what we do while we work as hard as we do. So just our internal staff, you know, and, and the fact that we talk about these KPIs, we brag about them. We have monthly meetings where we compare one month to the next, so everyone knows, you know, why we do what we do, they know the results and the data. So it’s, it’s just great for morale, it’s great for their motivation, you know, it makes everyone wanna try harder, do more, helping people, and it’s, it’s ama amazing feeling. It’s, it’s great to see. And then, you know, the other side of that is our, our partnerships. Y you know, we’re really strengthening our partnerships with home health, with, you know, some, the mobile, you know, a company called dispatch that we work closely with, where they can come and, and treat, diagnose, treat our clients that are home bound.

Laura Coyle (22:01):

We, you know, we’re getting good referral partners that way. And then the, the outcomes that we measure, we can now bring back to these referral sources. So our director of sales, John does a really nice job of putting together like a program where our sales team can, you know, go meet, whether it’s annually, quarterly, whichever appropriate for that referral source and say, these are our five patients, you know, that we received from you. These are the outcomes, you know, they had, this was their caregiver, this is the testimonial they gave us. We avoided a, a readmission by doing this, you know, and just kind of giving them a snapshot of how we took care of that client. And in turn they’re gonna wanna send us more, more people, more clients, more referrals. So that’s a win-win.

Michelle Cone (22:56):

Agreed. I really feel that that helps support repeatable business, right? They, it’s a true partnership relationship. I really feel that home care, non-medical home care is a linchpin to success for many models that are being explored currently by payers. And Laura dropped so many nuggets during that little presentation piece right there. But going back to her you know, saying that it builds that team morale and her entire team is invested in reducing readmissions. I think that that is often overlooked, especially in our industry with our caregivers. We see them as just being task driven, just checking the box on the care plan and not actually understanding what they actually bring to the table. And that without them, none of this can be successful, right? We’re not sitting here, Laura doesn’t have any agency. I don’t have, I’m not, none of us are having this conversation today without our caregivers, right?

Michelle Cone (23:44):

And as Laura mentioned earlier, no one knows our clients more intimately than those caregivers. If a care manager, an RN is going out for a visitor supervisory visit and only showing up every now and then, they may not fully recognize those nuances, those subtle changes that may be that client may be experiencing like our cl our caregivers, because they’re so intuitive, you know, that client might be resting more than normal, confused more than normal, active, more than normal, sleeping more than normal eating, or drinking less or more than normal. And any of that could be a change in condition that they can then alert the care team and they can reach out to those community partners. They can identify who best on the care team, either internally or externally, and meet the NER needs of that and that client to make sure that we’re being very proactive versus reactive when it comes to ensuring that we’re doing all that we can as a complete care team to ensure that our clients are able to continue to age in place and recover at home safely.

Amanda Sternklar (24:47):

Absolutely. I imagine even if caregivers do kind of fall into, you know, the, the day-to-day do feel like their, their job is just checking a box that also provides an opportunity to reengage them in the whole impact of the work that you’re doing.

Laura Coyle (25:03):

It’s, that’s super important. It really is. I, I’m proud that we do a nice job of that here because every compliment they receive, you know, every, even in internal, when we have a compliment for them, they receive a phone call from our staff, you know, saying, this family called here, they said this about you. You know, we think it’s important for them to hear it, even if they don’t hear it in the home, we need to pass that on to them and let them know that’s the impact you had on this family. And, you know, that’s job satisfaction for them. And then if they’re happy, they love their job, they project that, they project that into, you know, when they’re in that client’s home and they give better care, they’re more present. They’re, you know, caregivers of course they have a caring heart, you know, this is, this is a often thankless job for, for some of them. So we need to make sure we cover that for them. You know, many of our families do. We have great clients, but we make sure they hear it from us as well.

Michelle Cone (26:07):

And that does positively impact retention, which we know those numbers seem to increase year over year. When we look at caregiver turnover rates and doing everything that Lori just mentioned is essential, it’s necessary in order to bring those caregivers into the fold, make sure that we’re communicating how valuable they are to the success of client outcomes and that they lay this integral part of seeing that success follow through helps with retention for sure. And as Laura mentioned earlier, in order to go on our Go home program during New Jersey, you’re looking at 20, 25 hours a week because we need some meaty, robust hours in order to really make a difference and ensure that our collaboration with other healthcare partners is something that we can make an impact with that’s important as well. So it, it adds to their hours, right? And, and when they’re getting the hours that they need with the clients that they want and they’re making that impact and they’re keeping those clients home, they’re able to stay on shift and we’re able to retain them longer.

Amanda Sternklar (27:03):

That’s fantastic. So we’ve talked a lot about how much data is important to this, especially in communicating with referral sources. So aside from readmission rates, what are some of the other key metrics that you’re tracking? Either as part of this program or just in general when it comes to readmissions?

Laura Coyle (27:21):

So in general, you know, some other important KPIs that we track, you know, related, related to this topic. You know, we track hospitalizations, just general hospitalizations, not people who have been in the hospital or, or SN in the last 30 days, but you know, then those clients are existing clients. Once they are admitted, hospitalized, then we can place them on, you know, go home. Well, we do want to track them and, and watch them closely. So just general hospitalizations is one. Falls balls are, are big. That’s a huge track, you know, and, and just diving a little deeper into that, we do look for repeat caregivers within those falls, you know, is there a, a piece, you know, of education missing there? Is there a negligence possibly? You know, so we definitely, aside from just tracking a number, we look at the circumstances of who the caregiver was, repeat caregiver, repeat client, and, you know, address those infection.

Laura Coyle (28:28):

Infection is a big one for us. Utis are, I would say our, our number one reason for readmission, probably close, close second with falls, but, you know, urinary tract infection is a big problem in, you know, the older population and the, it, it’s complicated because it presents, it doesn’t present typically like it would in a younger person. You don’t get the same symptoms. You actually will get just confusion and sometimes, you know, weakness, lethargy. So it’s super important for us to identify that early, teach our care caregivers, give them those tools to know if you see this, this and this, call us. And then we can get in there quickly. We’ve prevented, you know, some, some hospitalizations that way. So tracking infections also in the same breath, you know, looking for repeat caregivers there within infections and UTIs. So then we know, do we have to target that specific caregiver to give her more education, her skill, you know, how is she bathing this client?

Laura Coyle (29:39):

So a little more supervision there, a little more, you know, reeducation needed. And you know, the the last thing I think that we look at that’s important for all of us, you know, through home care Pulse, you know, client and caregiver satisfaction, you know, client satisfaction right away that lets us know are we giving, are we providing quality service? Are they happy with us? And customer service, level of customer service, an important piece for both of those is communication. So if we’re communicating properly and well with that client and addressing these issues before it becomes, you know, a negative survey, then we’re giving, we’re giving them quality care, we’re paying attention to them before, you know, they even have the chance to, you know, say it on a survey, we wanna hear about it, you know, we do quality control ca calls in the first week of service and then continue throughout service. So that’s important to measure for us. We want our clients to be satisfied and happy. We’re doing our job there. Caregivers, same thing. You know, we, they’re equal, they are our client as well. They’re equally as important and we need to know that they’re happy in their, in their role here and they’re giving that client, you know, 100%. So those are just kind of a few, few of our really key metrics that we follow closely.

Michelle Cone (31:09):

Yeah, I think that just capturing data for data capture’s sake is, is not enough. You’d have to analyze what the numbers are telling you good. Or if there’s opportunity, just like Laura said, so that you can get ahead of that right before it becomes a, a, a, maybe a major issue. But it’s also with, you know, looking at, you know, is there a commonality with a physician, with a referral source, with a home health agency? Is there are, are we seeing some sort of commonality with higher hours versus lower hours caregivers, like Laura mentioned, you know, diagnosis. What are, what is the numbers telling us and how can, what can we extract from that data and how can we continue to dial in and improve our processes and the programs, I always say here at home, well our programs are never said it and forget it.

Michelle Cone (31:58):

I was just collaborating with Laura and some of her team members last week as we’re going through a quick review of our risk assessment tools. Is this still what we’re seeing? Is this state is sterile, accurate? Are we seeing something now that we didn’t see when we initially rolled out this program many, many years ago when I first joined home Home? Well, one of the first things I recognized was the opportunity for a robust, intentional transitional care program. We did not have one. And we live and breathe by that in the home health and, and facility space, right? So I wanted to take all that, bring it into home care and create something that allows us to really have an intentional program with meat behind it that where we can actually make an impact in reducing readmissions, reducing falls, increasing engagement, increasing retention, inre, increasing collaboration and buy-in from our healthcare partners. That’s very, very important here. And I, I consider this a program like this to be table stakes in this industry. Now I considered it table stakes years ago when we rolled it out, considered it table stakes now. But we continue to have to look at the data that our industry is showing what Home care pulse shows, what the C d C shows, what C m s is showing, and continue to optimize and improve our programs based off of data

Amanda Sternklar (33:10):

That Taylor so nicely to what I was just about to ask you. I always love speaking with folks who have a background in other parts of the care continuum and you know, we’ve, we’ve talked a lot about this podcast overall and even just today about how critical working across the entire continuum of care is. Can you share a little bit more about how focusing on reducing readmission rates has helped you to do that?

Michelle Cone (33:31):

It is, it is critical. It is mission critical. The demand for home care services is only increasing and home-based care support in general hospitals we saw during the pandemic are discharging patients home quicker and sicker and typically with only home health support at best. And this is due in part, while it is due in part somewhat to the pandemic, this shift has been happening for years. All of us involved in a patient’s care journey have to engage, interact, and collaborate if we’re gonna make an impact on reducing readmissions, cuz home health cannot do it alone. And I think our greatest challenge as an industry is education awareness. That we’re not just here to provide a d l support, but the benefit and the value of home care is reducing falls, reducing readmissions, collaborating. I know that oftentimes when our, when our agency care managers or sales teams or administrators call up and visit with a home health agency and say, we did an assessment today and this is the risk that we saw and we know that due to the discharge plan that I’m looking at, that you’re coming out to assess this patient tomorrow, how can we collaborate to make sure that between your therapy department, your skilled nursing, the physician that’s involved, our team, that we’re all working together collaboratively to ensure best outcomes for, for this shared client patient.

Michelle Cone (34:46):

Because the rehab team can’t do it alone. The physician can’t do it alone. The home health agencies cannot do it alone. Gone are the days of looking at patient care through a vacuum, only focusing on what we can do within our scope of practice. And in order to really see the true success in reducing readmissions and improving outcomes and preventing even admissions from occurring in the first place, we have to collaborate to ensure that the patient is at the center of what we do. And we all have a role to play in reducing UNN unnecessary readmissions. But when we break down those silos and we really communicate openly with the patient’s care team, we can work to our strengths ensuring that the patient, the family and, and everyone involved or getting the support that they need when they need it.

Amanda Sternklar (35:30):

Absolutely.

Laura Coyle (35:31):

I would touch, you know, just to touch on that, and I think I, I mentioned it earlier when I said, you know, the, we’re really trying to collaborate with the skilled nursing modality when we’re in the home together with them. And I hear it from our, our nursing team frequently, that they, they almost feel a little bit like a broken record, but they’re, they’re resilient. So, you know, they are constantly explaining what we do. I think there is still a lot of confusion out there about where do, where, where do we begin, where do we end, where do they pick up? You know, so as much as we can, as many times as we can to just teach, to talk about what we can do and promote that, I think that’s really invaluable. And once they, once they get it and once they understand it, they’re thrilled and it’s, you know, it’s like you’ve opened up this whole new world for them <laugh>. It’s really interesting. It’s interesting. They just never understood it. They know, they know we’re out there but they don’t understand exactly what we do. And measuring this data, talking about it, it, it just adds to our value adds to, you know, the, the benefit that they see.

Michelle Cone (36:46):

I absolutely agree and mean know, I think our greatest challenge and our greatest opportunity is education and awareness. You know, oftentimes when we, you know, at the agency level, when they enter those, those facilities, they’re like, yeah, we’ll we’ll give you a call If we have a a, a patient that’s gonna discharge that needs bathing or meal prep or transportation, it’s like, let’s really step back and speak about what we can really do for you, right? And what we can really do for the client, what we can really do for the facility and inpatient rehab and, and in short term rehab for skilled nursing, that, that therapy team is working very intentionally and intimately with those, those patients. And oftentimes the families too. I always noticed in the facilities space that when the patient showed up, they wanted to show up when mom or dad was in pt, right?

Michelle Cone (37:29):

That’s, that’s who spends the greatest amount of time with them. That’s who they wanna speak with on how their loved one is, is progressing and what do they think about the discharge plan and when should they should discharge and who should they discharge with and what are they gonna do when they discharge. And so understanding that they spend a significant amount of time, weeks, maybe even months in a skilled nursing facility, it could be up to a hundred days that they’re spending with this patient. They know them very intimately and they’re very connected to them and then they discharge them and they really hope that they make this successful discharge into the community. So how can we collaborate with those facilities and, and close the feedback loop, provide information back to them of this is what we saw, this is when the admission occurred, this is the program they’re on, this is what we identified as risks, this is the hours they’re receiving, this is who we’re collaborating with and this is what we’re gonna be tracking and providing valuable feedback to you, not only to help you with your internal structure, right?

Michelle Cone (38:24):

Cuz if we see something that may be commonalities again with, with maybe a certain physician or a home health or, or a diagnosis, we can relay that back to the facility and they can take a look at their own team and see is there something here that we can improve in our own processes as part of the discharge plan. So it really reinforces with the collaboration, the true partnership that we are all in this together. The readmission prevention doesn’t stop when they leave the building. That’s when really the time and the clock starts. And so now this new care team is shouldering this responsibility as we should. We shouldn’t accept a patient from a hospital or rehab facility if we aren’t going to work together collaboratively to focus on keeping them home and, and ensuring that safe discharge to community that’s successful discharge to community. So it’s more important now than it’s ever been before that the need is, is only going to intensify the, the acuity of patients that we’re seeing is only continuing to get more critical. And, you know, we really have to collaborate with everyone involved in the client’s care team to make sure that they’re getting and extracting every bit of value possible from all those care providers so that we can keep that client-centered focus at the forefront and ensure that they’re getting everything that they need to, to recover and and to do so safely.

Amanda Sternklar (39:44):

Absolutely. I wanted to circle back to something that you said cuz pretty much every time I speak to a home care provider who’s worked with the home health, who’s worked with facilities, I get a a pretty similar feedback or piece of information that folks outside our industry and frankly even folks inside of it, would be shocked at how much other parts of the care continuum don’t understand how home care works. And, you know, it can, it can go both ways, like home care also may not understand everything about home health, about hospice and how valuable being able to just be in the same room and, and get on the same page can be.

Michelle Cone (40:22):

Absolutely. I think we need to all fully understand when you’re in this space, not only what we do, but it’s, it’s arguably even more important to understand the other players in this space and those others within the care continuum. You know, before we talk to a home health agency, we need to know what is home health? How is it paid? What do they see? What do the referrals come from? Who are they managed by? What does c m s dictate that they can and cannot do? What is their average visit link? How many times can they see the patient per, per week or, or in, in an episode? All important for us to understand just, and, and in turn we want home health to understand that about us as well. That we’re more client driven. Typically we’re more of a private payer, family funded situation.

Michelle Cone (41:04):

It’s oftentimes not the client that’s paying for the services over 60% of the time. It’s the, the, the family that’s paying for those services. So this is all something that we absolutely have to look at and we have to educate cuz we do get a lot of pushback on, well, the client doesn’t need that or they can’t afford that, or there’s not an option here. And there absolutely may be with long-term care insurance, with Medicare Advantage opportunities, with va, with Medicaid. We don’t want them to be leaving opportunities on the table to receive home care hours because they think that the client themselves as the patient is unable to afford the services that we can provide.

Amanda Sternklar (41:38):

And I love that you all are being proactive because you can’t educate this, educate other folks about this in the middle of discharge. And I love that you’ve spoken about c creating those partnerships ahead of time and educating folks. So we’ve talked a whole lot about your program, about all of your thoughts around it. But I wanna leave folks who would be starting from, from scratch who aren’t even tracking readmission rates yet, let alone thinking about additional ways they can improve. What’s your one piece of advice? What’s the first step? What can they do today to get started?

Laura Coyle (42:13):

I love this question. So I have just a few very simple basic steps. So number one, just very simple. Make the decision to do it and commit to it. And this is something I use in business, I use in per personally, it’s a decision, don’t overcomplicate it. Make the decision that you’re committing to it. That’s number one. Number two, educate yourself on how develop a plan and what’s your best strategy. So you need to look at, you know, what system can you use? So for us, we use a hybrid of Wells, sky and Excel spreadsheet, maybe different for each person, but how will you track this? What tool will you use? And then the next step to me is probably in the most important is finding the right person or people to track this, document it and analyze it. Because if you have someone who doesn’t understand the value of it, who’s not bought into it, who isn’t going to be all in on it, then you have the wrong person for it. So choose the right platform, choose the right person to do it, and you will succeed. And I would say commit to it for a minimum of six months. You have to just, you know, it’s not gonna be, you know, a few short weeks, six months and you will see quality care being delivered, better outcomes. You may even get more referrals if you are reporting back to your referral sources.

Laura Coyle (43:56):

That’s it.

Michelle Cone (43:58):

Yep. Start

Laura Coyle (43:58):

Simple.

Michelle Cone (43:59):

Don’t, don’t, you know, the, you have to eat it one elephant line bite at a time, right? Start with something simple and digestible. And in, in our space in non-medical, even for agencies Laura’s size who are huge, right? Top 5% in the nation, it’s a little bit different for us versus skilled home health where you may have 10 admissions a week, right? And that’s just a moderately sized agency here. You may have 2, 3, 5 admissions a week and it’s much easier to track that if you’re being intentional in, in tracking those, those, the, those outcomes, right? So however you do it, I don’t care if it’s a dry erase board, it’s an Excel spreadsheet. If you’re writing it up in a notebook, whatever that needs to look like when you are admitting a client and they have come from the hospital or rehab, the greatest predictor of a readmission is a prior admission, right?

Michelle Cone (44:44):

So start there and, and then, you know, do some research and do some homework and be intentional. Be dedicated, you know, typically it’s not motivation that’s a, a challenge. It’s just making sure that we’re being very diligent and that we are being very disciplined in ensuring that the person that we’ve assigned to the team, and it may be multiple people that are responsible for, for capturing and tracking this information, are being held accountable to doing that. Right? And, and bringing that back to the table every week in your, in your weekly meetings and having a conversation about where are these clients? How are they doing? Is, did a readmission occur? If so, how, let’s have a conversation about that. But yeah, we all own a piece of the puzzle and we all own our space in, in this healthcare continuum of what we can do to, you know, drive down costs and provide greater outcomes for the clients that we serve. And we really do have to collaborate and work together as a team in order to see readmission reduction be successful.

Amanda Sternklar (45:41):

It’s amazing. I love that. Just, just start however you have to is the first step. Thank you both so much for joining me today. Cannot wait to to hear comments on this of all the folks who have, who have got gotten started tracking readmissions and their results. If you have a story that you’d like to share on vision like Laura and Michelle’s, you can find our guest submission [email protected] slash podcast. You can also find our previous episodes there or on your favorite podcast listening platform. Michelle, if folks wanna reach out to you to learn more about Home Wells programs, where’s the best place that they can reach you online

Michelle Cone (46:16):

At home? Well cares.com, you can ch you can reach [email protected]. And you can also reach out to any [email protected]. And if you’re interested in launching your own home care agency, you can reach out to [email protected] easy, easy.

Amanda Sternklar (46:29):

And Laura, if folks have any questions about the program or just any other questions for you in general, where’s the best place to reach you?

Laura Coyle (46:36):

Absolutely. You can reach out on LinkedIn. You can also reach out, you know, el home well cares.com. It’s l coyle, l c o y l [email protected]. And I’m happy to help. I’m happy to answer any questions. I would love to hear success stories if anyone does this, try for six months. And, but I’m, I’m happy to help anyone with any tips.

Amanda Sternklar (47:00):

So six months from now will be the end of the year, so I can’t wait to to hear some problem from this one. And if you have any questions about the podcast or just wanna connect in general, I have Amanda Stern Clark on LinkedIn, that’s s t e r n as in Nancy, k l a r. We’re. And Michelle, again, thank you so much for your time. Looking forward to talking to you again soon.

Michelle Cone (47:20):

Thank you so much.

Laura Coyle (47:21):

Thank you Amanda.