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...

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Story Behind Fundamentals of Home Health!

Hello & Welcome to our blog!

For the first blog, I want to share why I decided to build a standardized education and orientation platform for home care agencies.....

During my post as the Director of Quality, Education & Program Development in the area's biggest Home Health Agency, the agency was under constant pressure to grow!  Growth meant capacity management, and in order to grow capacity we needed a solid recruitment and retention strategy. 

Our program had the following barriers:  

  1.  Hiring full time educators was not an option (initially!) We were part of a major corporation and getting FTEs approved would have meant giving up our first born or at a minimum a limb!  Also, it would have taken closer to a year just to get approval and finally hire an educator!
    1. So all of us in management were tagged for teaching part of orientation! Our clinical management, Utilization Review and Quality Consultant all had to dedicate 2-4 hours per week to...
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Pneumonia Management: Field Decision Tree - Home Health

In the past few blogs, I have talked about clinical management of vulnerable high-risk population in home care.  I want to use the algorithm (see below) as an example to demonstrate the standardized approach.  I suggest home care agencies  use the following operational processes for high-risk patients: 

  1.  At start of care, obtain patient specific parameters and orders from the physician (NP, PA) managing patient's home care services
  2. Establish baseline vitals, infection status, pain level (comfort function goal,) functional capacity (e.g. use 6 minutes walk test), behavioral status, etc.
  3. If/when patient's condition deviates from baseline for the worse, initiate the protocol and go down the decision tree.  

Algorithm below is an example of pneumonia management in field.  If you are a home care agency looking to develop similar processes, 

  1. Work with your referring physicians and hospital systems to establish protocols for the specific patient...
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Skipping to Covid-19

No Elective Surgeries and Skilled Nursing Facility population displacement has major implications for Home health agencies as these agencies will be managing a much high risk and high acuity patients. 

We are not sure what the post Covid-19 world will look like, but one thing is for sure! This is the time for home care agencies to shine!  Home care agencies that can deliver high-quality, cost-effective care will play a central role in managing Covid-19 and high-acuity non-Covid-19 patients in home environment. 

This new role will require home care agencies to shift its practices and be able to manage higher acuity population in home environment.  In order to accomplish this effectively, here are a few things to consider for home care leadership

Clinical & Operations Management

  • Educate and train clinicians in managing high-risk population at home
  • Build a risk based clinical case management strategy where your agency identifies the patient’s risk at...
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