At Partners In Care, we believe healing doesn’t just end when a patient leaves the hospital. For many in Central Oregon, especially elderly patients or those managing chronic medical conditions, the time following a hospital discharge is a vulnerable period. Without the right support, there’s an increased risk of hospital readmission, which can lead to further health challenges.
Home health care bridges the gap between acute care in a hospital and recovery at home. By offering skilled, compassionate care at home where patients feel most comfortable, we help prevent unplanned hospital admissions and promote better outcomes for patients. In short, medical care in a patient’s home offers a positive and healthier healing experience.
This article explores how home health care services can reduce the rates of hospital readmission and why that’s important for individuals, families, and the entire community.
Understanding Hospital Readmissions
Hospital readmission refers to a patient’s return to the hospital shortly after being discharged, often within 30 days. While unplanned hospital admissions may be necessary, sometimes a readmission can reflect gaps in care, unmanaged symptoms, or a lack of proper follow-up. Hospital readmissions are particularly common among elderly patients and those with chronic medical diseases like heart failure, COPD, or diabetes.
Unfortunately, hospital readmission rates remain a challenge for healthcare systems nationwide. Going back to the hospital after discharge places a heavy burden on patients, disrupting recovery, causing stress, and increasing the risk of long-term complications. For healthcare providers, readmissions also strain resources and impact overall patient outcomes.
The Role of Home Health Care in Reducing Readmissions
Home health care offers a systematic medical review, skilled nursing, and therapy services after a hospital discharge. Providing quality home health care for patients after a hospital stay addresses their medical needs and promotes independence, while reducing the chances of another hospital admission.
Caring for patients in their home is a safer and more supportive environment for healing, especially for older adults managing chronic medical conditions.
Here’s what patients can expect from a quality home health care team:
1. Comprehensive and Personalized Home Health Care Plans
After an inpatient hospitalization, each patient requires an individualized plan tailored to their specific needs. A home health team conducts a thorough, systematic medical review upon admission to services. The patient’s health status is assessed, hospital discharge instructions are reviewed, and physicians collaborate to develop a plan that addresses:
- Medication management
- Chronic disease management
- Wound care
- Mobility and safety needs
- Education for patients and caregivers
This attention to detail ensures a smooth transition from hospital to home and promotes better outcomes for patients by reducing the likelihood of complications that lead to readmission.
2. Managing Chronic Medical Conditions at Home
Chronic medical diseases, such as heart failure, diabetes, COPD, and kidney disease, are leading causes of hospital readmissions. Managing these conditions after a hospital stay requires close monitoring, timely interventions, and consistent education.
Home health professionals help patients manage symptoms and avoid the emergency room by:
- Monitoring vital signs and symptoms
- Providing medication education and adherence support
- Adjusting care plans as needed
- Coordinating follow-up with healthcare providers
For elderly patients in particular, proactive management of chronic medical conditions can prevent the worsening of symptoms that often result in an unplanned hospital admission.
3. Skilled Nursing and Rehabilitation at Home
For many patients recovering from surgery, stroke, or other acute care events, rehabilitation services like physical and occupational therapy are crucial for the healing process. Skilled nursing and therapy teams deliver these services in the patient’s home, reducing the need for travel to outpatient facilities.
Teams focus on strengthening mobility, restoring function, and reducing the risk of falls, all factors that contribute to lowering hospital readmission rates. For those who may otherwise require a skilled nursing facility, home health can be a safe and effective alternative that promotes healing in a familiar setting.
4. Supportive Home Health Care for Older Adults and Their Families
Older adults often face complex health challenges after a hospital stay. A quality home health team understands that caring for elderly patients requires a compassionate, holistic approach. Here’s what you can expect from comprehensive home health services:
- Education and support for family caregivers
- Assistance with activities of daily living
- Emotional and psychological support
- Monitoring for signs of health decline
The Impact on Patient Outcomes and the Health Care System
Reducing hospital readmission rates isn’t just about lowering numbers; it’s about improving lives. For patients and their families, avoiding a return to the hospital means fewer disruptions, less stress, and a greater opportunity to focus on recovery.
For healthcare providers and the broader health care system, lower readmission rates translate to:
- More effective use of resources
- Reduced healthcare costs
- Improved patient outcomes and satisfaction
- Better coordination across the continuum of care
Who Can Benefit from Home Health Care?
There’s a wide range of patient conditions that can benefit from home health care. Here are some typical scenarios where home health can play a supportive role in healing:
- Have recently been discharged from an inpatient hospitalization or skilled nursing facility
- Are managing chronic medical conditions
- Require wound care, IV therapy, or medication management
- Need physical or occupational therapy after surgery or injury
- Are elderly and need additional support to recover at home
- Are receiving palliative care or health care for hospice patients
Reducing Hospital Readmissions for Hospice and Palliative Care Patients
Avoiding the emergency room and unnecessary hospital admissions is a fundamental goal for patients receiving palliative care or health care for hospice patients. This is a sensitive and important time in the life of the patient where the goal is dignity and peace, not more days in the hospital.
Here’s what you can expect from your hospice or palliative home health team:
- Pain and symptom management
- Emotional and spiritual support
- Education for families on when and how to seek urgent care
- 24/7 access to on-call nurses to address urgent needs
- Personalized support and education for families about hospice and goals for palliative care
Partners In Care offers Quality Home Health Care
With over 45 years of experience as a trusted healthcare provider in Central Oregon, Partners In Care delivers the region’s top home health, hospice, and palliative care services. Our multidisciplinary and compassion team includes skilled nurses, therapists, social workers, and aides who are all committed to reducing hospital readmission rates and improving patient outcomes.
Our entire organization is dedicated to providing the highest quality health care in our patients’ homes, where recovery, healing, and comfort thrive.
Ready to Learn More about Home Health Care?
If you or a loved one is recovering from a hospital stay or managing chronic medical diseases, home health care could be the key to better health and independence.
Contact Partners In Care today to explore how our home health services can help prevent hospital readmission and improve your quality of life.
Frequently Asked Questions About Home Health Care and Reducing Hospital Readmissions
1. What’s the difference between home health care and home care, and how does that impact hospital readmissions?
Home health care involves skilled medical services provided by licensed professionals such as nurses, physical therapists, and occupational therapists. It is typically ordered by a physician after a hospital stay or an acute medical event and focuses on recovery, medical treatment, and preventing complications that can lead to hospital readmission.
Home care, on the other hand, typically refers to non-medical support services such as help with bathing, dressing, cooking, and companionship. While home care improves quality of life and supports activities of daily living, it doesn’t replace the skilled clinical services necessary to manage health conditions that could otherwise result in an unplanned hospital admission.
Combining both types of care often results in better outcomes for patients by ensuring their medical and personal needs are met, reducing hospital readmission rates.
2. How does home health care help patients transition from a skilled nursing facility (SNF) to home?
Many patients are discharged from a skilled nursing facility after recovering from surgery or illness but still need continued care at home. Home health services provide an essential bridge by continuing medical oversight, therapy, and chronic disease management after discharge from the SNF.
This continuity of care ensures patients remain stable, reduces the risk of setbacks, and helps avoid the emergency room. It also supports better long-term patient outcomes by providing a smooth, structured transition back to independent living or assisted care at home.
3. Is home health care effective for patients with cognitive impairments like dementia in preventing hospital admissions?
Yes. Home health care plays a vital role in helping patients with cognitive impairments such as Alzheimer’s disease or other forms of dementia avoid unnecessary hospital readmissions. These patients often face higher risks for injuries, infections, and complications from chronic medical diseases because they may struggle to manage their health independently.
Home health nurses and therapists are trained to work with individuals with cognitive decline. They provide specialized care, medication management, and caregiver education, which can prevent complications and avoid the need for unplanned hospital admissions. Additionally, home safety assessments can help prevent accidents that commonly lead to hospitalization in this population.
4. What role does remote patient monitoring (RPM) play in home health care to prevent hospital readmissions?
Remote patient monitoring (RPM) is an innovative technology that allows healthcare providers to track a patient’s vital signs, symptoms, and health data in real time while the patient is at home. This technology is particularly helpful for patients with chronic medical conditions such as heart failure, diabetes, or COPD.
By continuously monitoring key health indicators, RPM enables early detection of health deterioration. Home health teams can intervene quickly—often before symptoms become severe enough to require hospitalization. RPM enhances home health care by adding an extra layer of proactive care and contributes significantly to reducing hospital readmission rates.
5. What is palliative care at home and how does that help reduce hospital readmissions for patients with advanced illnesses?
Palliative care focuses on improving quality of life for patients with serious or life-limiting illnesses, such as advanced heart failure, cancer, or chronic lung disease. At home, palliative care provides comprehensive symptom management, emotional support, and coordination of care, which helps prevent unnecessary hospitalizations.
By effectively managing pain, breathing difficulties, nausea, and other complex symptoms, home-based palliative care reduces crises that often lead to emergency room visits and hospital readmissions. It also empowers patients and families to make informed decisions about care goals, helping them avoid interventions that may not align with their wishes or improve their quality of life.