Home Health Clinical Strategy Based on Referral Source

More than ever, Covid-19 crises has demonstrated the value of having a holistic approach to patient management.  Covid-19 crisis has shown how age, underlying chronic conditions, socioeconomic status, and other risk-factors can influence mortality of a patient. 

In my prior post, I talked about how home care agencies providing high-quality, cost-effective care can position themselves as value-adding entities during this pandemic. All patients being admitted into home care are not alike, agencies must develop clinical training and management strategies that help clinicians case manage patients coming from different referral sources with different referral source based risk factors.  

Since majority (>75%) of home care patients admitted into home care services are from in-patient settings (short term acute care hospital, Skilled Nursing Facility, inpatient acute rehab) it is paramount for home care agencies to develop a specific clinical assessment focus and clinical management approach based on referral source.  In my opinion, agencies should have a specific strategy for the following referral groups and subgroups:

• Acute Care Hospital
  1. Patient appropriate for SNF but refused SNF care or is too high-risk to be placed in SNF care
     • Agencies must work with hospital case management especially during Covid-19 Pandemic to clearly identify patient’s status, comorbidities, rehab status at time of referral, safety status etc.
  2. Patient qualifies for Palliative Care Services but refused services.
  3. Patient qualifies for Hospice level of care but refused services.
• Skilled Nursing Facility
• Community Physician
  • In my experience, this specific referral group flies under the radar for quick decline and hospitalization within first few days of care (if not, before care begins)
  • If you are a physician or a home care agency admitting a patient from community (e.g. PCP is referring a patient after office visit,) to home care; ensure that a lean referral process is in place to help mitigate any delay in care.

In conclusion:

1. Collect and analyze your agency (branch) specific data
2. Standardize education and training based on identified gaps
3. Build frontline clinical case management to help mitigate risk identified 
4. Track progress and communicate results to key stakeholders