Home Health Partnership
A COLLABORATIVE APPROACH TO REDUCING
RE-ADMISSIONS
What’s wrong with this picture?
 Each department may excel in their respective practice, but
without communication and collaboration the outcomes
may not turn out as anticipated.
The Partnership between ValleyCare and Alliance
Home Health Care
 Ongoing exchange of patient centered information
 Monthly round table meetings to gain insight into
challenges, successes, improvement of practices
 Telephone, Fax, and Email follow up on cases
 Shared information between departments to help
develop new tools to facilitate continuity of care
Using the same
teaching materials
in all patient
settings
Provides continuity and consistency
in content once the patient returns
to the community setting.
Daily Phone Call
Follow-up
between skilled
nurse visits
Using agency specific
forms
 Identifies subtle changes in
condition designed to prevent
escalation of emergent care.
CHF Alert Form
Provides succinct information to the physician
to expedite orders or direction to the home
health provider
Standard CHF
Patient Report
A communication tool for physicians
who prefer written updates
Handoffs
INFORMATION EXCHANGE WITH CASE
MANAGER AT INTAKE STAGE
AT START OF CARE (SOC) – ONE PAGE
PHYSICIAN STANDING ORDERS FOR CHF
PROVIDED TO HOME HEALTH AGENCY (HHA)
THOROUGH REVIEW OF HISTORY AND
PHYSICAL BY HHA INTAKE STAFF
CRITICAL INFORMATION, ORDERS PASSED
ON TO HHA STAFF CARING FOR PATIENT
Communication
PHONE
FAX
IN PERSON AT CARE CONFERENCES,
MEETINGS
SUPERVISOR STAFF REVIEW OF ALL
DOCUMENTATION FROM ALL HOME HEALTH
DISCIPLINES FOR IMMEDIATE
INTERVENTION IF NEEDED
Success
Stories
 Patient discharged without
emergent care (38 days on
service) and no re-admission
 Patient/caregivers knowledgeable
and compliant with lifestyle and
behavior changes
 Patient/caregivers knowledgeable
of early intervention/prevention
of exacerbation
Challenges
 Non-compliance
 Severity of disease
 Communication challenges between providers/
departments, between shifts/weekends
Anticipated Mutual Outcomes
 Patients remain in the community independent with
disease management by the end of episode of care
(60 days) if needed.
 Both providers have thorough knowledge of patient’s
condition in real time.
 Reduction of re-admissions
Take-away
COMMUNICATION AND COLLABORATION ARE
VITAL TO THE SUCCESS OF PATIENT CARE
FROM THE TIME THE PATIENT WALKS
THROUGH THE DOOR OF THE FACILITY
UNTIL THE LAST CLINICIAN LEAVES THE
PATIENT’S HOME
Contact Information
ALLIANCE HOME HEALTH CARE, INC.
12657 ALCOSTA BLVD. SUITE 155
SAN RAMON, CA 94583
OFFICE: 925-275-9300
FAX: 925-275-9304
DOROTHY COFFEY, MSN, RN, CNL
ADMINISTRATOR/DPCS
[email protected]