Home Health & Hospice Week

Another home health success story shows how the service can curb hospital readmissions.

A KentuckyOne Health program, the Health Connections Initiative, is helping patients in Louisville who are at high risk of being readmitted to the hospital, reports the Courier-Journal. KentuckyOne Health, the largest health system in the state, has more than 200 locations including physician practices and HHAs, and includes the former Jewish Hospital & St. Mary’s HealthCare and Saint Joseph Health System, along with the University of Louisville Hospital and James Graham Brown Cancer Center.

The program sends a support team into the homes of participating patients to "help them not only manage their medical condition but to really overcome any other barriers that they might have to good health, whether it’s lack of reliable food access or transportation (or) connecting with a primary care doctor," KentuckyOne Health VP Alice Bridges told the newspaper. "We really try to help people kind of get to the root causes of what might cause them to cycle in and out of the hospital."

In the 12 months before enrolling in the program, 26 of 72 patients were readmitted to the hospital within 30 days of being discharged, the newspaper says. But after graduation, only six patients were readmitted within 30 days. Patients also report better outcomes in areas such as depression and managing their conditions.

KentuckyOne Health recently received a three-year, $1.5 million grant from Catholic Health Initiative’s Mission and Ministry Fund to support the program, which currently serves about 40 patients and has a capacity of up to 50. The program generally includes up to 90 days of home visits from team members and is staffed by VNA Nazareth Home Care, the Courier-Journal says. It consists of a registered nurse, licensed practical nurse, social worker, community health worker, peer support specialist, and a dietitian.

Unlike in traditional Medicare, nurses spend most of their time on education. Patients receive help with tasks such as making medical appointments.