Better Coordination Needed Between Hospital Physicians and Home Health Care Providers Interview with:

Christine D. Jones, MD, MS, Assistant professor Director of Care Transitions, Hospital Medicine Group University of Colorado School of Medicine

Dr. Jones

Christine D. Jones, MD, MS
Assistant professor
Director of Care Transitions, Hospital Medicine Group
University of Colorado School of Medicine What is the background for this study? What are the main findings?

Response: The background for this study is that referrals to home health care at hospital discharge have increased over recent years.  Yet, care coordination including information exchange and communication is often suboptimal between the hospital and home health care and may contribute to medication list discrepancies and even hospital readmissions.

We spoke with focus groups of home health nurses and our main findings were that improvements in key areas could care coordination after hospital discharge.

Specific solutions included:

1) Clearly defining the accountability for home health orders after discharge between hospitalists and primary care providers

2) Changes to insurance requirements that currently only allow physicians to write home health orders so that nurse practitioners and physician assistants can also write home health orders

3) Enhancing access for home health agencies to hospital electronic health records and direct phone lines

4) Encouraging liaisons from home health agencies to meet patients in the hospital to align clinician and patient expectations

5) Direct coordination between home health nurses and clinicians or pharmacists to resolve medication discrepancies

6) Ensuring that detailed information about cognitive and behavioral health is included in information provided to home health from referring hospitals What should clinicians and patients take away from your report?

Response: Efforts to improve care coordination should incorporate input from the multiple stakeholders in a care transition.  Given that home health nurses expressed uncertainty about which clinician to contact for orders and questions, clearly defined accountability for home health care between hospital clinicians and primary care clinicians is needed.  In addition, efforts to improve care coordination with home health care should support direct communications between clinicians, improve alignment of expectations for  home health care between clinicians and patients, focus on reducing medication discrepancies, and prioritize safety for both patients and  home health care nurses. What recommendations do you have for future research as a result of this study?

Response: Studies that assess the timeliness and completeness of information received by home health nurses before and after care coordination interventions would be of interest.  In addition, studies to evaluate the effect of multi-faceted care coordination interventions on patient outcomes including emergency department visits and hospital readmissions, would be of great interest.

Disclosures: My disclosures are as follows:

Funders: Dr. Christine D. Jones is supported by grant number K08HS024569 from the Agency for Healthcare Research and Quality for this work. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

This work was also supported by a grant from the University of Colorado, School of Medicine, Department of Medicine, Division of General Internal Medicine.

Prior Presentations: This work was presented at the Society of Hospital Medicine meeting in San Diego, California on March 7, 2016 and at the American Geriatrics Society meeting in Long Beach, California, on May 19, 2016. Thank you for your contribution to the community.

Citation: Christine D. Jones, Jacqueline Jones, Angela Richard, Kathryn Bowles, Dana Lahoff, Rebecca S. Boxer, Frederick A. Masoudi, Eric A. Coleman, Heidi L. Wald. “Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients. Journal of General Internal Medicine, 2017; DOI: 10.1007/s11606-017-4104-0

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.