1. Reducing Readmissions Providing Home Health Services to the vulnerable population

2. Reducing Readmissions Vulnerable population can be defined as the: Uninsured: Lack health care coverage to provide resources for community-based services. Underinsured: health care coverage available – Health care plan options offer suboptimal to no coverage for community-based services.

3. Reducing Readmissions Statistics January – June 2013 Referrals – Total – Total Indigent DME and Supplies

4. Reducing Readmissions Strategies for overcoming barriers Partnership with home health vendors – Negotiating partnership contract that supports providing services to a threshold of indigent population. Safety Net process – Identification of readmission high-risk population Uninsured young adults (age group less than Medicare eligibility) Medicaid – Minimal eligibility – Screening and application process for pending coverage

5. Reducing Readmissions Strategies for overcoming barriers cont’d – Charity funds: screening criteria – Internal resources pharmacy – Medical team based pharm-D support – Safety Net process to support home infusion Laboratory services – Offers post-discharge services for monitoring interval therapeutic values Follow-up: primary care physician (PCP)

6. Reducing Readmissions On-site Home Health Vendor partner Daily huddle – Identify readmission high-risk patients – Diagnosis/chief complaint Emergency department Acute care area Outpatient clinic – Disease management Weekly partnership meeting – Tracking and trending data: Home Heath admissions Payer –mix Re-admissions Evaluation of services

7. Reducing Readmissions Early referral initiation Unit-based case management structure Initial discharge planning assessment Weekly multidisciplinary team meeting Unit-based focus Discussion emphasizing disposition – Discharge barriers – Solidify safe discharge plan

8. Reducing Readmissions Patient/family education – Care management discharge planning – Unit-nurse post-discharge callback – Care management follow-up for identified customer care concerns Tracking and trending for frequent ED utilizers: – Community-based social service support

9. Reducing Readmissions Participant participation Share ideas on how to overcome the barriers of providing home health services to the vulnerable population.