HomeBest Practices → Next Generation ACO post-discharge home visit Medicare waiver

Next Generation ACO post-discharge home visit Medicare waiver Print E-mail
Written by   
Thursday, 14 December 2017 08:37

To lower readmission rates, the number of incident to billable visits will jump next year to nine in the first 90 from the current two in the first 30 days.
The new rules eliminate the time intervals between visits. If a patient requires more upfront attention, a post-discharge team can evaluate her or him three times in the first two weeks, and therefore reduce costs by preventing an avoidable readmission. 
Not all nine home visits may be needed and the first in-home assessment is the most critical. The doctor should send an experienced registered nurse, someone who has done either case management or social services and thus knows how to assess the patient physically, functionally and socially.
That professional will find out how much the patient can do on her or his own, whether a caretaker or family is there to assist, and whether certain measures are in place such as power of attorney and notification of next of kin. The nurse will also assess the patient’s condition, which will then dictate the next visits and follow-up office appointment.
Again, much depends on the initial assessment: What types of care would help the patient stay in the home? How much assistance does the individual need? How would the doctor be alerted to send a care team so the patient doesn’t need to call 911?
The answers can help the patient stay healthier and more independent, and could bring down the national 18 percent Medicare readmission rate.

Last Updated on Thursday, 14 December 2017 08:40

Website design, development, and hosting provided by