Care Link

Promoting Quality Outcomes and Preventing Re-hospitalizations

For patients at moderate risk for re-hospitalization successful outcomes of hospitalizations continue well past discharge.

Measures of success for a hospitalization extend beyond the day of discharge:

  • HHCAHPS scores capture retention of education regarding medications
  • Managed care network penalties for excessive re-hospitalizations
  • Medicare penalties for re-hospitalizations within 30 days of discharge

For hospitals to be successful in the present healthcare environment, they must not only plan for an effective discharge, but particularly for patients most at risk for re-hospitalization, ensuring that the plan is put in place and is working.

Defining Characteristics of Moderate Risk

The following patient characteristics represent a moderate risk for re-hospitalization:

  • Diagnosis of a chronic disease such as CHF, DM, COPD, Asthma
  • Mobility or ADL deficits
  • Limited family or community support availability
  • Does not meet criteria for subacute or home care services post-discharge, or does and declines offer

Interventions for Moderate Risk Patients

For patients at moderate risk, a follow-up phone call is made by the Care Link Team of Catholic Home Care within 48 hours of discharge, and the following tasks are completed:

  • Interview the patient and/or caregiver to confirm that post-discharge instructions were understood, including confirmation of the follow-up MD appointment and has transportation plans.
  • Telephone medication reconciliation
  • If problems are identified during this call, and cannot be rectified over the phone, arrangements are made for an RN home evaluation visit within 24 hours of the call for assessment and potential intervention.

For patients at high risk for re-hospitalization, defining characteristics of high risk for each hospital participant, an analysis of discharge, and readmission patterns is made to determine the profile of patients with chronic conditions (CHF, DM, COPD, Asthma, etc.) or acute illnesses / procedures with highest incidence of readmission. From this profile, the characteristics of patients at highest risk for readmission are developed for referral to Care Link Plus of Catholic Home Care.

Interventions High Risk Patients

For patients at high risk, a follow-up phone call is made by the Care Link Team within 24 hours of discharge, and in addition to the same tasks that are completed for the moderate risk patient, these steps are taken:

  • CHS Home Support Services technician makes a home visit within 48 hours of discharge to install telehealth monitoring equipment and instruct patient in its use.
  • Care Link nurses then monitor biometrics daily and contact the patient and/or caregiver if issues arise. If problems are identified that cannot be rectified over the phone, arrangements are made for an RN home evaluation visit within 24 hours of the call for assessment and intervention. Care Link’s Telehealth Department of Catholic Home Care Recommended Criteria for Telehealth Monitoring
  • Recent hospitalizations or Emergency Department visits
  • Any condition requiring frequent monitoring or trending of health data to facilitate clinical management
  • Individuals who can avoid admission to alternative living facilities if monitored at home
  • History of poor adherence with diet, medications or self-monitoring

Physician Benefits

  • Customized to meet specific disease/chronic management needs
  • Complete, objective, clinical and subjective data is available upon request
  • Allows pre-emptive care, supporting adjustments to treatment plan or medications
  • Reinforces patient education and compliance to treatment plan
  • Breaks the cycle of emergency care and hospital re-admissions
  • Supports documentation of time spent on care plan oversight

Did You Know?

  • That telehealth is available for your patients upon hospital discharge, even if they do not have home care services?
  • That telehealth units can measure blood pressure, pulse, pulse oximetry, weight, and tidal volume for patients with diagnoses such as: heart failure or COPD? * That Registered Nurses monitor your patients on a daily basis?
  • That as the physician, you can have secure access to your patient’s data?
  • That telehealth gives you a daily window to your patients’ progress, and gives you the chance to note changes and/or trends sooner?
  • That telehealth is a proven means to decrease re-hospitalization?
  • That patient satisfaction with telehealth is nearly 100%?
  • That telehealth also allows you to ask targeted questions of your patients to better ascertain their comprehension about their disease process?
  • That telehealth devices are easy to use, and give patients and families comfort and security in their home environment?
  • That the physician sets the biometric parameters for ranges appropriate for each patient?
  • That other services will be available to your post-discharge patients, including other home safety devices, and phone assistance as needed?
  • That you can order telehealth with one phone call by calling (631) 656-1631
  • Interested in getting started? To make a referral call (631) 656-1631