Keeping Patients at Home After Home Healthcare Discharge

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How much time does your agency spend preparing patients for a successful stay at home after discharge from home healthcare? With the implementation of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, it's time to think about that handoff from home healthcare to the community. The Visiting Nurse Associations of America (VNAA), in partnership with the Association for Home Health Quality and Innovation (AHHQI), recently launched a new “Discharge to Community” module on our best practice website, the VNAA Blueprint for Excellence ( to help agencies plan and develop effective discharge strategies. Home healthcare agencies (HHAs) began reporting the IMPACT Act “Discharge to Community” performance measure on January 1, 2017. The Centers for Medicare and Medicaid Services (CMS) states the claims-based measure captures:
HHA's risk-standardized rate of Medicare FFS patients who are discharged to the community following a HH episode, and do not have an unplanned readmission to an acute care hospital or LTCH [long term care hospital] in the 31 days following discharge to community, and who remain alive during the 31 days following discharge to community (CMS, 2016).
Therefore, HHAs are evaluated not on the absolute number of readmissions, but on the excess, or risk-standardized rate based on the projected rate.
The VNAA-AHHQI Work Group began by examining current agency practices used to identify risk factors for readmission and prepare patients for discharge. The group reviewed current evidence and found little research specific to readmissions after home healthcare discharge. Expert consensus identified a number of key priorities.
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