PHC ranked in the top 20% in Acute-Care Hospitalization and 80% in Oral
Medication Management among participating home care agencies
Home care professionals are often the first line of defense in preventing hospital readmissions because they see first-hand what a patient deals with in the home setting during the recovery period. Peninsula Home Care is being recognized on a national stage for qualifying as “Agency of the Month” by the Home Health Quality Improvement (HHQI) Network. They are being recognized for their efforts in reducing hospital readmissions and oral medication management. Peninsula Home Care ranked in the top 20% in Acute-Care Hospitalization (ACH) and 80% in Oral Medication Management rates.
“We are honored to be acknowledged by HHQI, as it has created a collaborative effort among healthcare providers to create evidence based best practices to help reduce the number of readmissions associated with medication management,” said Nancy Bagwell, area director of operations, Peninsula Home Care. “We will continue to work diligently to improve patient outcomes and quality of life in our community.”
Peninsula Home Care took into account all risk levels from insufficient funds for medication and lack of transportation and missed follow up doctor appointments to fall risks and other chronic disease symptoms. Peninsula Home Care was recognized for initiating the following Best Practices in efforts to reduce hospital readmissions:
- Screening patients upon admission for high risk of re-hospitalization and tailoring care to meet the individual needs of the patient
- Establishing communication along the continuum of care for the patient (i.e. our team with primary care physician, surgeon, specialist, etc.) as needed and appropriate
- Planning in the transition of care from hospital to home
- Ensuring the patient, family, and caregivers are participating in the plan of care for recovery and using methods such as “teach back” to educate the patient, family and/or caregiver
- Medication reconciliation completed within 48 hours of discharge / Medication Management
- Notifying physicians if a patient is identified as “high risk for readmission”
- Assisting the patient with establishing and preparing for follow-up appointments
- Using interdisciplinary teams to coordinate patient care
- Implementation of telehealth to assist patients in learning signs and symptoms of exacerbation and maintenance of disease process to increase patient accountability
- Making patients aware that PHC is available 24/7 and to reach out before going to the ER
- Comprehensive discharge planning (i.e. facilitating discharges to rehab facility such as Genesis or nursing homes with detailed instructions and partnership or referral to other community healthcare providers.
“It starts with our very first visit to a patient’s home,” added Bagwell. “Medication management can be confusing especially to the many home care patients that are on complicated drug regimes. Our team is dedicated to assessing both the patient and caregiver’s ability to administer medications, perform a medication reconciliation, and seek to identify risk of nonadherence.”
By tracking patients, the PHC team was able to proactively intervene, communicate challenges to doctors and other healthcare providers and develop a plan for the coordination of care that would best fit the patients’ needs at home.
About Peninsula Home Care
Providing care for more than 30 years, Peninsula Home Care, in Salisbury and Ocean Pines/Berlin, Maryland, ensures that all patients are involved in their plan of care and strives to give them every opportunity to maintain their independence in the home. The agency has served more than 39,000 patients on Delmarva and was designated as a Peninsula Regional Medical Center preferred home care provider in 2017. For more information, visit www.peninsulahomecare.com.
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