Description: The IOM Future of Home Health Care report highlighted multiple ways for home health agencies to position themselves for success as health care delivery systems move toward patient-centered cross-setting care approaches. Recommendations include a focus on collaborating across multiple settings to deliver interdisciplinary plans of care informed by evidence-based practices. In the context of increasing referrals to home health after hospitalization, home health agencies are ideally positioned to be key partners for hospitals in efforts to reduce hospital re-admissions. Yet, multiple barriers exist to effective care coordination between home health and clinicians in hospitals and other settings. In addition, more evidence is needed to guide care as patients move from the hospital to home health. The participants will receive an understanding of successful models of care transitions, challenges to implementing interdisciplinary plans of care across settings, and opportunities to build evidence and improve care transitions to home health care. In addition, the presenter will discuss how home health agencies can participate in research to build the home health care evidence base. Objectives: • Describe trends in home health referrals after hospitalization • Define payment policies that affect care transitions from the hospital to home health • Describe successful models of care transitions that can be applied to home health • Describe barriers and facilitators to care coordination for patients discharged from the hospital to home health • Discuss opportunities to build evidence in home health care for care transitions
Faculty: Christine D. Jones, MD, MS, is an Assistant Professor of Medicine at the University of Colorado, Denver where she is the Director of Care Transitions and Director of Scholarship for the Hospital Medicine Group. Dr. Jones graduated from Emory Medical School and completed her residency and chief residency, at the University of New Mexico in Albuquerque, New Mexico. She completed a Preventive Medicine Residency and a Research Fellowship at the University of North Carolina at Chapel Hill in 2013. Dr. Jones is funded by the Agency for Healthcare Research and Quality and the National Institute on Aging to complete research involving care transitions from the hospital to home health care. Her goal is to improve care coordination between clinicians in different settings to optimize outcomes for recently-discharged patients.
Continuing Education: 1.5 clock hour Administrator/Alternate and 1.5 contact hour for nurses.
Texas Association for Home Care and Hospice
3737 Executive Center Drive, Suite 268
Austin, TX 78731
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