Care Transitions And Home Care

For the many who have expressed interest, what follows is an update from the perspective of home care and the Home Care Alliance on Care Transitions – and the intersection with STARR efforts in this state.   A number of members are already involved in many of these efforts, but more input is welcome and needed.

The Alliance’s Care Transitions Task Force has met several times to continue work on a document we are calling our “Opt In” framework:   “Optimum Performance Standards for Transferring Patients To and From Home Health Care.” We have a good first draft and various pieces are being rewritten by Task Force members.     This will be a tool we provide to member agencies;  but it will also serve as a framework for partner providers to help them understand what they can expect when making a referral to home health.  This group will meet again in Brockton on April 27th at 11am.

Two additional efforts are underway in relation to the IHI STAAR project.  IHI is working with their project team on a Field Guide for Home Health – which will mirror those that have already been published for Physician offices and Skilled Nursing Facilities. These Guides – which I am happy to forward to anyone would like them – focus on encouraging use of evidence based best practices in the area of readmission reductions.   Some of these practices  – obviously  – have to do to with what happens during  “handovers.”  We have had a call with IHI on the outline for home health,  and several members have agreed to spend some time with IHI in Cambridge on either April 29 or 30 on actually beginning to draft the full document. Cheryl Pacella of Hebrew Senior Life HomeHealth Care is playing a lead role in facilitating this.

Additionally, the STARR project is looking at reducing readmissions through an ‘Enhanced Admission” tool. Given that our agency members on STARR teams – as well as those of us on the STAAR Steering Committee – have identified that hospitals may NOT be appropriately identifying who needs and could benefit from home health care, the team is looking at potentially modifying a QIO tool developed as part of HHQI to recommend be used as part of a process for screening all – or high risk patients – for home care.  We are needing to do a thorough industry review of this tool and make recommendations to IHI.  This will eventually be discussed on a STAAR home health call.  These calls are now open to any  interested agency (see previous post to this blog.)

Finally, one of the first action items from the state’s Care Transitions Plan will be to revise the three page discharge form to meet information needs of sending and receiving health care entities.   A Task Force with HCA representation will start meeting this month. As available, we will share for input with  this group.

These are all ambitious projects that can not be done without member input.  If you are not yet involved, it’s not too late to be so.  Just reply here or send me an email.     Thank you to all who have been supporting these efforts.

Pat Kelleher

Return to

STAAR Project and Home Health

Mid way through the first year of a multi-year project, the state STAAR (STate Action on Avoidable Rehospitalizations) Project has begun looking more closely – at both the project and collaborative team level – at the role of home health care in readmission reduction. The project has recently added a special “Learning Community” for home health agencies and office practices that convenes for one hour a month.   Any home agency, regardless of participation in STAAR, is welcome on these calls.  Call-in information is at the bottom of this post.

Additionally, the STAAR project is bringing to light the possible underutlization of home health services.  One effort to address this may be incorporated into an “enhanced admission” best practice for all STARR hospitals that will begin the process of assessing home-going needs upon admission.   Members of the Home Care Alliance are working with IHI on a discharge criteria tool to be embedded in the enhanced assessment to screen for appropriatenss for home care.

The STAAR teams is also working on a guide for “Creating an Ideal Transition to a Home Health Agency”  that will highlight practices,  tools and case studies of promising changes.

The STAAR project represents a significant step forward in using cross continuum teams to make a real difference in readmission rates and in the projects own words to “create new public and professional norms in which avoidable emergency department visits and avoidable rehospitalizations are seen as system defects.”

Whether you are directly involved in a community collaborative or not, every home health agency is invested in this project’s work and outcomes.

Learning Community Calls for Home Health/Office Practice

Wednesday, April 7 from 1:00 – 2:00 PM, ET
Wednesday, May 5 from 1:00 – 2:00 PM, ET
Wednesday, June 2 from 1:00 – 2:00 PM, ET

To WebEx Website:

Call In Number: 866-469-3239
Session Number: 352 310 006

Session Name: STAAR OP & HH Learning Community Call