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Improving patient transitions from hospital to home

Practical advice from nurses

Elliott, Brenda PhD, RN, CNE; DeAngelis, Marybeth BSN, RN

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doi: 10.1097/01.NURSE.0000525985.72817.16
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SHARING INSIGHT from one practice area to another may help to improve patient outcomes and decrease readmissions. To gather some advice, the authors of this article called on a handful of colleagues with many years of home health experience. They brainstormed helpful pearls about the needs of home health patients to share with those caring for them in the acute care setting.

Nurses who haven't worked within the highly regulated home health arena may have many misconceptions about the rules and standards of practice. Understanding regulatory requirements, assessing for key information about how the patient will manage at home, and establishing expectations can contribute to a successful transition from the hospital to the home health setting. Ultimately, decreasing readmissions for patients with chronic disease would be a win for all levels of healthcare as it moves toward a value-based arena focused on access, quality, and cost of care.

This article describes the challenges of home healthcare, the regulatory environment, and practical information to help patients make a smooth and safe transition from an acute care setting to home health.

What are the challenges?

Hospitals, home health agencies, long-term-care facilities, primary care offices, and many other healthcare entities share the great responsibility of caring for patients who become ill. Often this care is delivered during an acute episode requiring short-term intervention. With the rapid increase of chronic disease within the United States, this care is becoming increasingly long-term: According to the CDC, in 2012 approximately half of all adults had one or more chronic health disorders.1 Heart failure, diabetes, and chronic obstructive pulmonary disease (COPD) are among the chronic diseases most often requiring frequent hospitalization.2 It's no surprise then that hospitals and healthcare providers are helping many patients learn to manage chronic diseases, and doing so becomes exponentially more difficult with each additional chronic disease a patient experiences.

Advances in technology and research, coupled with new care models and fee structures, have all had a major impact on delivering healthcare.3 Continued pressure to decrease hospital length of stay results in fast-paced throughput of patients, leaving staff little time to thoroughly address patients' complete discharge needs.4

To further compound the issues, a National Assessment of Adult Literacy survey reported that only 12% of U.S. adults had a proficient level of health literacy.5 Most patients have at best only an intermediate level of understanding of most aspects needed to manage their health and prevent disease. Low health literacy has been associated with poor health outcomes, such as higher rates of hospitalization and underutilization of preventive health services.5 Furthermore, low health literacy can impact a patient's understanding of hospital discharge instructions as well as the understanding of family and caregivers.

Over the past decade, it's become increasingly apparent that healthcare providers must work collaboratively across many levels of care to ensure patient safety and well-being. One reason is that more Americans are living longer with chronic diseases.

According to the American Association of Colleges of Nursing, nurses make up the largest portion of healthcare workers within a hospital.6 They play a critical role in the safety and well-being of patients admitted for acute illness or exacerbation of a chronic illness. Teaching patients what they need to know to return home safely, manage their chronic illness, and avoid frequent hospitalization is no small task. Shorter hospital stays impact the time nurses have to plan and teach patients for discharge, leaving patients and their families with less information than they need to manage illness.4

Voice of experience

Based on their experiences, home health nurses can offer advice about what they see in the home setting that can help nurses working in the acute care setting to collaboratively manage care for these patients. Many nurses, such as those without a baccalaureate degree, haven't had education in or exposure to community health, an umbrella that covers home healthcare.7 More than 60% of the nursing workforce is employed within a hospital setting with little or no experience outside of that setting, making it doubly challenging for nurses to understand the scope of patient issues beyond acute illness. Many things that aren't always within patients' control can go wrong once they've left the hospital.

Nurses need to continually work toward identifying patients who need to be referred to other levels of care and provide optimal discharge planning.4 To do so, they need to understand regulations affecting home health patients.

Regulatory requirements

Patients need to meet certain regulatory requirements to qualify for certified home healthcare under the Conditions of Participation (COP) from the Centers for Medicare and Medicaid Services (CMS). Most insurance providers follow the same guidelines. Acute care nurses must be familiar with key criteria that can help to establish a discharge plan. According to CMS guidelines, patients must be under the care of a physician, confined to the home, and require intermittent skilled services to qualify for home healthcare.8

As defined in CMS guidelines, patients must be “confined to home,” or homebound. Patients must have an injury or illness that requires them to have an assistive device or special transportation or they must need the assistance of another person to leave the home. Patients must also have a basic inability to leave the home, with leaving the home requiring a considerable and taxing effort. Leaving the home should be infrequent, of short duration, and primarily for medical reasons. Leaving home for hair appointments, religious ceremonies, and attendance at gatherings for special events such as funerals or graduations is acceptable.8

Because daily nursing visits can't be supported for long-term needs, patients must also require intermittent skilled care.8 For this reason, it's important to begin teaching hospitalized patients about their current illnesses and management of any chronic diseases.

At this time, nurses should assess patients' ability to manage at home. Examples of what to inquire about would be how they prepare meals, how they perform bathing and other activities of daily living, how they get in and out of their home, if they have anyone who can assist them, and if they manage their medications independently. Responses to these lines of inquiry may raise a red flag that patients require postacute services.

The last regulatory requirement is timeliness of care. The COP states a home health agency must see a patient within 48 hours from referral to the agency unless the physician orders a specific start of care date. Because of this, a gap may exist from discharge until the home health nurse arrives.9 Too often, patients are told the nurse will be visiting the same day or the next day, but this doesn't always happen.

Such a delay can be problematic for patients with multiple medical issues and healthcare needs posthospital discharge. For example, because heart failure is the leading cause of readmission within 30 days of hospital discharge, many transitions of care interventions have surfaced in the past decade.10 Examples include standard risk assessment, care pathways for both acute and postacute services, telephone follow-up calls, and coordination of care for follow-up care with the primary care physician.11 Even so, many hospitals and other levels of care still need strategies to lower their readmission rates and avoid financial penalties. Preventing readmissions has become everyone's challenge.

Although not a current regulation, seeing high-risk patients within 24 hours continues to be a strong focus. Meeting this goal nationwide will be a challenge for home health agencies.

Advocating for the right level of care

Patients have many options for continued care postacute hospitalization. With the push to be more patient-centric, patients can choose not to accept recommended discharge services, sometimes to their own detriment. There's no place like home—and many patients choose home over a rehabilitation facility without thinking about how they'll obtain their medications, prepare their meals, buy groceries, or even safely walk to the bathroom. Discussing with patients, families, and care teams the benefits of a short stay in a rehabilitation facility can prevent the transition to the wrong level of care for patients who qualify for a higher level of care. Palliative care discussions can also help patients and families choose the correct level of care when they're faced with the difficult decision of hospice or home healthcare. If an acute care nurse thinks a patient wouldn't be safe at home for up to 48 hours, when a home health nurse could make the initial home visit, advocating for a different level of care could be appropriate.

For patients who still choose to return home, strongly recommend a caregiver stay with them until home health services are initiated to ensure their safety. Urge patients or families to schedule a follow-up appointment with their primary care provider before hospital discharge.

Chances are that patients seen in the hospital frequently are also frequently being seen by the local home health agency. Hospital nurses who are collaborating with the case management department and their home care coordinators, if they're present in a facility, may improve the odds of a successful transition to home.11

Establishing realistic expectations

Patients need to be aware of the difference between skilled home health services—such as those provided by a licensed professional such as a nurse or occupational, physical, or speech therapist—and nonskilled services, such as provided by unlicensed assistive personnel (UAP) or housekeepers. Skilled services include providing wound care for a pressure injury or surgical wound, or monitoring a patient with a serious illness or unstable health status.12 Unskilled services include personal care and housekeeping.

Many patients expect same-day or next-day admission to home health services, and this expectation can't always be accommodated. Patients referred to skilled home health services may not be seen for up to 48 hours after hospital discharge.

The frequency of visits by the nurse, physical therapist, or home health UAP will depend on patients' need for skilled services, which must be supported by clinical documentation provided by the home health nurse. The home health agency (which may provide skilled or nonskilled services or both) is a partner with patients and families and isn't the sole care provider.13 Nonskilled care can always be provided by private-duty home care agencies, but this comes with an out-of-pocket expense for the families or patients.

In acute care settings, nurses armed with the knowledge of home health regulations can help to communicate realistic expectations to patients and families, ultimately improving understanding of what services home health agencies can provide. Patients and families can then plan accordingly.

Transition of care intervention

According to Dusek et al., nurses are key communicators and collaborators in coordinating the transition of patients from one level of care to another.13 Healthcare organizations and teams must work together with nursing to establish their roles in transition preparation processes. (See Processes to address in patient transitions of care.) Identifying those patients who are at high risk for readmission using predictive models during the acute care stay and communicating the transition of these patients to home health services will help decrease readmissions.

In their systematic review, Dusek et al. state that while the literature supports using multiple strategies to improve transitions of care, more research is needed to strengthen the evidence supporting improved patient outcomes.11 Most home health agencies do prioritize high-risk patients to be seen as soon as possible.

Managing acute and chronic illness upon discharge from the acute care setting depends on the active role of nurses and successful discharge planning.11 For example, ensuring that all equipment is present in the home and in working condition always benefits patients' transition to home. The home health nurse continues with assessment, education, and collaboration with the healthcare team to prevent readmissions. Organizations have implemented many interventions to mitigate the infamous revolving door of repeat hospitalizations for patients with chronic diseases. Consider the following situations.

  • When patients are admitted to the hospital with heart failure, acute care nurses should ask if they have a working body weight scale at home. If not, nurses should initiate a conversation about the importance of obtaining one before discharge, as well as educate them about the guidelines for measuring weight daily. Specifically, patients should obtain weights every morning at the same time, after urination, wearing the same amount of clothing. They also need to know why daily weights are important and when to call the healthcare provider, such as after gaining 3 to 5 lb (1.4 to 2.3 kg) in 1 week. Patients who can't obtain accurate daily weights may need to seek medical attention more often.14
  • If patients with diabetes are admitted for hyperglycemia, it's critical to ask if they have a working glucometer at home, if they know how to use it correctly, and if they know what to do with the results. The healthcare provider can provide a prescription, families can secure a glucometer, and instruction to patients and families on its use can begin during the hospital stay. Discharging patients without a glucometer increases the risk of readmission.15
  • Patients with COPD should have a working nebulizer, knowledge of oxygen therapy and how to use prescribed medications correctly for acute or chronic illness, and an understanding of the importance of early treatment for COPD exacerbations. Nurses in acute care settings can assess the patients' ability to manage respiratory issues before discharge, especially the proper use of inhalers.

When asking questions, nurses need to start with some inquiry related to what patients will need to manage their disease upon discharge. Having a body weight scale, glucometer, or sufficient knowledge about supplemental oxygen use is basic to managing the chronic diseases mentioned. They're too often missing in the home when home health services arrive. As a result, patients may have to wait several more days or weeks until the proper equipment is obtained, placing them at increased risk.

Role of telehealth

Telehealth may be another good option for patients with chronic illnesses. Many home health agencies have a telehealth program. Physicians must order telehealth and set patient-specific parameters for monitoring. Telehealth equipment is installed in patients' homes. Every morning patients obtain their weight, BP, heart rate, and pulse oximetry, if needed. These measurements are transmitted to the home health agency and reviewed by a skilled professional. Home health nurses managing these patients are informed of changes in weight and vital signs and patients' physicians are notified about possible changes in treatment needed to prevent rehospitalization.

Telehealth equipment may also have built-in disease-specific questions that help identify a potential exacerbation, along with educational information for patients to review. A retrospective study by Thomason et al. showed a decrease of 11% in all-cause hospital readmissions when telehealth was used.16

Acute care nurses must be aware of the role telehealth can play in assisting patients to manage their disease at home and know how they can promote its benefits to patients, especially those with heart failure. For example, acute weight gain remains an important indicator of worsening heart failure; with timely adjustments in treatment in the home, hospital readmissions can be prevented.14,17

Improving handoffs

Because hospital-based unit nurses and home health nurses don't often interact, communication and collaboration for a quality handoff of care are essential for keeping patients safe and at home.11 Some hospitals have a case management department or home care coordinators to help address home health needs. Nevertheless, a good handoff starts with acute care nurses who remain curious about their patients' health and are eager to assist in improving patients' quality of life by knowing how they manage at home. This concept is best described as relationship-based care and specifically the care provider-patient relationship, or one in which the patient or family is kept the central focus.18

Besides disease management, medication safety and discrepancies are some of the biggest challenges home health nurses face, according to our colleagues in this field. Many nurses have to rely on a hospital discharge list, medication containers in the home, and patient recall to determine what medications patients should be taking. Patients with cognitive changes or with caregivers who are managing multiple medications of their own are at higher risk for medication mismanagement at home.19

One strategy for minimizing discrepancies is to have families or caregivers bring all medication containers into the hospital for medication reconciliation. Medication reconciliation can uncover poor management practices that can be improved before discharge home. Ideally, communication between healthcare providers would occur during this window but often it doesn't, leaving patients at risk. Collaborating with patients, their family, and other caregivers can help prevent medication errors after patients return home.19

Safe at home

Most patients need many levels of healthcare across their lifespan. Healthcare professionals, particularly nurses, must be adept at caring for patients no matter where they are. Understanding the resources patients have at home, along with their ability to understand discharge instructions and obtain prescribed medications and necessary equipment, is the first step toward a safe transition to home.

Processes to address in patient transitions of care11

  • Hold transition planning meetings.
  • Identify patients' needs and goals for care.
  • Plan transition and follow-up for both sending and receiving healthcare providers and settings.
  • Prepare patient and family for self-management.
  • Perform medication reconciliation.
  • Communicate and collaborate to minimize hierarchical health system barriers that could interfere with patient safety and continuity of care.


1. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion. 2017.
2. Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:f7171.
3. Leonard K. Hospitals of yesterday: the biggest changes in health care. 2014.
4. Bowles KH, Ratcliffe SJ, Holmes JH, Liberatore M, Nydick R, Naylor MD. Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients' 12-week outcomes. Med Care. 2008;46(2):158–166.
5. U.S. Department of Health & Human Services. Office of Disease Prevention and Health Promotion Health Communications Activities. America's Health Literacy: Why We Need Accessible Health Information.
6. American Association of Colleges of Nursing. Nursing fact sheet. 2011.
7. American Association of Colleges of Nursing. The impact of education on nursing practice. 2017.
8. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7, Home health services. 2017. c07.pdf.
9. Centers for Medicare and Medicaid Services. Home health agency (HHA) survey protocols. 2011.
10. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail. 2013;6(3):606–619.
11. Dusek B, Pearce N, Harripaul A, Lloyd M. Care transitions: a systematic review of best practices. J Nurs Care Qual. 2015;30(3):233–239.
12. What's home health care?
13. Types of home care agencies.
14. Saha S, Kapoor M, Ete T, et al. Weight monitoring as an indicator of re-hospitalization in patients with heart failure. Int J Res Med Sci. 2016;4(11):4834–4837.
15. Rodriguez A, Magee M, Ramos P, et al. Best practices for interdisciplinary care management by hospital glycemic teams: results of a Society of Hospital Medicine survey among 19 U.S. hospitals. Diabetes Spectr. 2014;27(3):197–206.
16. Thomason TR, Hawkins SY, Perkins KE, Hamilton E, Nelson B. Home telehealth and hospital readmissions: a retrospective OASIS-C data analysis. Home Healthc Now. 2015;33(1):20–26.
18. Koloroutis M. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2004.
19. Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to examine the home health safety lens. 2015.
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