Home Health: A Bridge in the Continuum of Care

By Patricia Driscoll

Continuity in care during and after a hospital stay is a goal shared across the health care industry.  Each provider -- be it the specialist or surgeon for the event that originated a hospital stay, the hospitalist or the primary care physician -- understands the negative effects of operating in silos within an increasingly complex and fragmented health care system.  A patient’s discharge from a facility back into the community can be one of the most critical points in maintaining continuity, because ineffective coordination often brings the patient back to the point of re-admission.

Advances in information technology, such as electronic health records, play an important role in information sharing, but technology plays only one, albeit critical, part in addressing continuity.  Home health care also serves as a valuable bridge between a hospital stay and the successful transition to independence at home. 

In addition to the provision of services such as skilled care and therapy, home health care staff serve as the clinical eyes and ears in the patient’s home, observing and filtering information on the patient’s progress after discharge.  This filter function increases efficiency for all providers following the patient.  Home care staff can assess a patient’s issues and alert the correct provider to facilitate follow-up where appropriate or simply provide reassurance to the patient and family.  Working as a part of the total care team, home care staff serves as a liaison or lifeline for the patient, identifying critical information that circumvents a trip to the emergency room or re-hospitalization. 

Assisting with continuity of care is one vital role home health care can play, but it’s also important to note the patient benefits of home health.  Patients are often eager to get out of the hospital, but anxious about leaving the security of around-the-clock care.  Home health once again serves as a bridge, facilitating patients’ recuperation and rehabilitation as they gain back their full independence at home. 

As health care in the United States evolves to meet the growing mandate for change across the industry, each provider segment must identify new ways for increased efficiencies.  Home health care can be a valuable partner in the continuum, increasing efficiency while maintaining the more important goal of better patient care.