House well being reaps dividends from Signify Well being’s transition-to-home program – House Care Every day Information

Signify Health has become an unexpected home health advocate since launching its Transition to Home solution nearly six months ago. Transition to Home is a clinical and social support program that helps hospitals bring Medicare patients home for 90 days after being hospitalized.

Marc Rothman, MD

“You’d be surprised how many people have requested home care for you, but for a number of reasons that doesn’t happen,” Marc Rothman, chief medical officer of Signify Health, told McKight’s Home Care Daily.

Signify Health – a Dallas-based company that leverages analytics and technology to power healthcare provider networks – has enabled Transition to Home in 50 hospitals in a dozen states. So far, the program has helped 3,000 patients get home from the hospital.

Signature Health launched Transition to Home in February to help Clinically Integrated Networks (CINs) and Responsible Care Organizations (ACOs) reduce costly hospital readmissions. The program engages patients through phone and face-to-face visits to improve outcomes by helping drug management, addressing social determinants of health, and monitoring other health issues.

Rothman said home nursing often plays a tremendous role in reducing readmissions, but elderly patients sometimes turn it down because they don’t know Medicare is paying for it or they don’t want caregivers in their homes.

“Often times we find that patients need a little encouragement to activate the home health services that would not have been ordered if they weren’t needed,” Rothman said. “In the end, we become lawyers for the house health insurance fund to ensure that they can activate the services they have ordered, such as physiotherapy, occupational therapy or speech therapy.”

Rothman said there have been cases where Transition to Home has recommended home health care recertification for patients to avoid possible hospital readmissions.

The Centers for Medicare and Medicaid Services (CMS) said that nearly one in five Medicare patients, for a fee, returns to hospital within 30 days of discharge. CMS estimates hospital readmission costs about $ 26 billion annually to Medicare, of which $ 17 billion is potentially preventable. CMS aims to reduce this through hospital readmission reduction programs, joint austerity programs, and quality improvement organizations.

Subjects:

Home Health Medicare Seniors

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