Background: Communication between home health care agencies and referring facilities is important for comprehensive care for patients. Yet, both home health care providers and hospitalists feel that this communication is frequently lacking.
Purpose: To implement weekly teleconferences to discuss patients recently discharged from the Rocky Mountain Regional VA Medical Center (RMR VAMC) who are initiating or resuming home health care services to discuss their hospital course, follow up needs, and issues identified during home health care initiation.
Description: This project began in January 2019 by conducting a needs assessment survey of both home health providers and the VA hospital medicine group to identify potential areas for improvement. Results of these surveys indicated that home health care clinicians felt they were provided with insufficient access to information about patient hospitalizations, that home health orders were inadequate to guide management of their patients, and they reported difficulty reaching an appropriate clinician with questions about a patient’s home health orders. VA hospitalists reported their home health orders are inadequate in communicating pertinent information about the patient’s hospitalization to home health care agencies and they frequently feel concerned about not being able to provide enough information in home health orders. In March 2019, we initiated weekly teleconferences that included: a senior-level Registered Nurse (RN) from a local Home Health Care agency, an RN from the Home Health service from RMR VAMC, and a VA hospitalist. The teleconferences were held to discuss patients recently discharged from an inpatient medical stay who were initiating or resuming services with the Home Health Care agency. We used a standard script for each patient where each member of the call would review specific details about the patient’s hospitalization, home health orders, and initial home health visit for establishment of care.To date, we completed six conferences where we discussed 13 unique patients. Modifications made to the planned protocol included changing calls out to a bimonthly schedule in instances where there were not new patients to discuss. In addition, we decided to discuss some patients on multiple calls to follow up on certain planned action items outside of the pre-planned script. We regularly identified issues regarding medication management, order authorizations, follow up appointments, and new health concerns. A recurring concern raised by the home health RN was the challenge they face in being able to contact the patient’s primary care team on the same day with clinical concerns.
Conclusions: Our teleconferences have demonstrated that both inpatient and home health care clinicians experience problems with communication of important details needed for successful transition of care. Our teleconferences revealed frequently important clinical information is incorrectly communicated or omitted from home health care orders. We also found that home health care providers frequently identify important patient needs that through our teleconferences can be addressed rather than waiting for outpatient follow up appointments. We continue to strive for a better line of communication for the home health care agencies to contact clinician teams. In future iterations of this project, we intend to include a representative from primary care.