Atlanta, GA- Trella Health, the leading source of post-acute outcomes data and provider performance analytics, was recently published in the Journal of the American Medical Directors Association (JAMDA) for their research study. The study, titled, “Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries” examined patient characteristics and outcomes of Medicare beneficiaries who received complete and incomplete home health referrals after hospital discharge. To the knowledge of Trella, they are the first to complete a study that examines the relationship between home health referral completion and patient outcomes in the Medicare Fee-for-Service population-based on Medicare Fee-for-Service claims data. Their motivation behind completing the study was to provide insight into post-acute care, and for the results to serve as a resource for both acute post-acute care providers.
The results of the study concluded that approximately 29% of the 724,700 hospitalizations in the dataset had incomplete home health referrals after discharge, and that almost 1 in 3 patients discharged with a status of home health does not receive the home health care instructed to them. Additionally, patients with incomplete HHA referrals are more likely to be nonwhite and dual-eligible relative to patients with complete referrals. In conclusion, complete home health referrals were associated with lower mortality and readmission rates, but higher spending.
“Home Health is a fundamental step in a patient’s care as they re-enter the home after a hospital visit,” stated Ian Juliano, CEO of Trella Health. “Complete home health referrals can save hospitals nearly 168.6 million dollars by lowering readmission rates, a saving that offsets a large percentage of the home health costs. In addition, the impact to payers is even greater when considering all of the unnecessary professional claims incurred as a result of that avoidable hospitalization.”
Trella’s study also focused on the reasons behind incomplete home health referrals after hospitalization. Some of these include the, primarily, male populations unwillingness to accept assistance, or their preference to rely on spousal care. For dual-eligible patients, the lower rate of home health referral completion is perhaps due to home- and community-based services being viewed as a substitute for home health care. Lastly, lower home health referral completion rates among nonwhite beneficiaries may reflect lack of trust in healthcare providers. Additional system-related issues include lack of communication between healthcare providers, missing documentation to support the homebound requirement for Medicare, staffing shortages when scheduling care, gaps in hand-offs between hospitalists and providers, and a patient’s misperception of the services available to them.
Christine Cook, Senior Data Scientist at Trella Health, stated “The repercussions of incomplete home health referrals cause a multitude of damaging effects, from the lack of quality care for patients in need to the increases in hospital costs due to readmissions. We must continue to evaluate our transitions of care to ensure that patients are provided with proper education on the value of home health care.”
Trella notes that the rate of incomplete home health referrals after hospitalization may change as a result of recent changes in Medicare’s payment system, known as the Patient-Driven Groupings Model (PDGM). PDGM is expected to incentivize home health to strengthen their referral relationships with institutions, which could also have implications for home health referral completion. Stronger networks between home health and hospitals could help increase the referral completion rate after discharge from the hospital. In the conclusion of Trella’s research, they stated it reveals the need for a better understanding of the causes of incomplete home health referrals at the system, provider, and patient levels and that addressing these challenges could lead to improved outcomes, including lower mortality and readmission rates.
Read the full press release here.
About Trella Health
Trella Health is the leading provider of actionable insights for healthcare networks, ACOs, and the post-acute care market. We believe that to achieve smarter growth in today’s value-based care economy, who you choose to work with is everything—whether it’s your referral sources or your network partners. As one of only a few companies in the country deemed an Innovator under the Centers for Medicare and Medicaid Services’ Virtual Research Data Center Program, Trella has access to 100% of Medicare Part A and Part B claims and Medicare Advantage data. We analyze and standardize billions of data points from across the continuum of care, and provide the insights our customers need to identify, engage, and manage the best partnerships for their business.