A hospital admission is a stressful event for an older adult, and when a client is discharged to go home, our duty is to ensure they have all the resources and support they need to successfully remain independent for their home care or in-home care in Sandy, Utah. Often times, the client may experience what is called Relocation Stress Syndrome. This is a consequence of stress caused by moving from one facility to another. For a senior or person with medical challenges, it can be very difficult for them to transition from 24-hour, round the clock care back to their home environment. For the client, returning home after a hospital or rehab stay may sound easy but for many it opens the door to repeated falls, injury, malnutrition, loneliness and medication non-compliance. They may feel anxious, fearful, even hesitant to return home even though that has been their primary goal all along. Once the social worker or discharge planner mentions the word “discharge” it can cause apprehension for both the client and their family. Usually, this anxiousness and apprehension is mirrored by the social worker or discharge planner. Their anxiety is valid. According to nationwide statistics, one in five Medicare patients return to the hospital within a 30-day period after an acute hospital or rehabilitation stay. It is one of Resolute Home Care's top priorities (based in Sandy Utah), is to make sure the patient is transitioning as seamless as possible.
How: A Resolute Home Care Manager will recognize at admission that the client is a potential readmission risk and implement the GoHomeWell Post Medical-Care Program. An in home care program to help ease their worry by implementing a list of duties for the care taker.
What: A Resolute Home Care Manager utilizes an in-home Readmission Risk Screening Tool to identify if a readmission risk exists and then addresses readmission risk factors. If a readmission risk is recognized, the Care Manager will implement the GoHomeWell Program. Home care for any of our local clients based in Sandy Utah and surrounding cities is what we specialize in doing.
Needs Addressed with the GoHomeWell Program. Each individual has unique needs and wants. We will accommodate these by providing the best in home care practices for that person.
First 48: The most critical time for a client is the first 48-hours home after a facility discharge. Going home from 24-hour facility care to little or no home care can be a challenge. It is important that the client focuses on their recovery. They should receive plenty of rest, maintain proper hydration and nutrition and take medications as prescribed. Resolute is the solution!
Welcome Home Cleaning: Often the client has not been home for weeks, even months. Their home is not as they left it. Laundry and light housekeeping can be a difficult or even impossible task for the client or family to perform once they return home from a hospital or facility. Often, the physician will not authorize the client to resume these duties until after their follow-up appointment. Resolute Home Care is the solution!
Food Facelift: Food items left in the refrigerator or in the pantry may have exceeded their shelf-life. This can render the food no longer safe for consumption. Proper nutrition is necessary for the client to regain strength while remaining on the road to recovery. Resolute Home Care is the solution!
Medication Reminders: Medication non-compliance is a key driver in hospital readmissions. When discharged, the client will more than likely have new or changed medications. Studies suggest that proper medication usage is one of the most important factors in contributing to lowered readmission risks. Clients that do not adhere to their medication regimens have a poorer prognosis than those that do. Resolute Home Care can perform medication reminders. We can also pick-up or arrange pick-up for new medications called in to the client’s pharmacy at time of facility discharge. Resolute Home Care is the solution!
Physician Appointment Compliance: Inability for the client to attend their scheduled Primary Care Physician (PCP)/Post-surgical follow-up appointment(s) is a key driver in increasing the client’s opportunity for a hospital readmission. Resolute can remind, encourage, drive and/or accompany the client to their physician(s) appointment(s). Resolute is the solution!
Bridge the Continuum: Poor communication between post-acute providers can result in confusion around follow-up care which often leads to providers operating in silos. This lack of communication when providers have a common goal, the recovery of the client, can be detrimental in the overall health of the shared client. The Resolute Home Care Manager will open the lines of communication between healthcare providers. We will communicate with the home health agency information such as new medications in the home, etc. We will also partner with the home health team to suggest and reinforce the client’s home exercise program on off-therapy days and after therapy discharge. This can reduce falls and hospital readmissions and improve the home health agency’s quality measures (outcomes). Resolute Home Care is the solution!
Data Tracking: Analyzing rehospitalization trends and sharing this data amongst acute and post-acute providers is essential in determining how the rehospitalization could have been avoided and what can be done in the future to reduce the risk for future clients. The Care Manager will utilize the Quality Care feature in Clear Care to input the client and capture data. The Care Manager will also implement the GoHomeWell Readmission Tracking Form and provide to the sales professional to complete. Once the form is complete and captures a snapshot of the client for 30 days post-discharge, a copy will be provided to the hospital and/or facility social worker/discharge planner. This is something that a good in home care company should be doing for your loved one. That is why Resolute Home Care is one of the top agencies in Sandy Utah.
Value Based Care: Value Based Care is the idea of improving quality and outcomes for patients. Value based programs reward health care providers with incentive payments for the quality of care they provide to people with Medicare. Incentives focus on value by rewarding better outcomes and lower spending. This model represents a drive for improved patient outcomes at a lower cost.
Hospitals: Reducing hospital readmissions has been the focus of many in the health system, due to Medicare imposing financial penalties on hospitals with high readmission rates. Preventing patients from returning to the hospital after discharges — an idea that has become a rallying cry for home health and home care agencies alike — is a key part of the shift toward value-based care. Moving forward, health systems that can successfully slash readmission rates will thrive, while those that cannot will likely suffer penalties and payment reductions.
SNF’s: SNFs are intended for short-term stay (under 100 days) following hospital discharge to provide the medical, rehabilitation and other support that family and caregivers are not trained or equipped to provide. In 2018, Medicare began to penalize SNFs as well as the hospital that treated the patient if a rehospitalization occurs within 30 days of discharge from the hospital.
Home Health Agencies (HHA): CMS is adding incentives to improve their readmissions performance. HHA 30-day readmissions and 60-day hospitalizations are publicly reported on the CMS website. Although the HHA revenue is not negatively affected, as are hospitals and facilities, an agency’s top line of revenue can be influenced by patient and medical provider impressions of quality, as interpreted by their ratings. CMS is now calculating a home health specific Medicare cost per beneficiary plus a metric measuring discharged to community that will compare the ratio of discharged patients who stay out of the hospital for 30-days after their home care discharge. CMS will be including these new measures in their value-based reimbursement models and programs.
Resolute Home Care came through for my mom and helped me so I can continue to work while supporting my mom.
My dad was needing more care than I could give. I looked for a local home care agency and found Resolute Home Care to be within budget and what my dad needed.
My wife and I had debated about assisted living for her dad and found that what we really needed was a part time home care. This helps us so we can both work and spend time with him after we get home.