MedicalResearch.com Interview with: Christine D. Jones, MD, MS Assistant professor Director of Care Transitions, Hospital Medicine Group University of Colorado School of Medicine MedicalResearch.com: 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 (more…)