Home Health Visits and Readmissions

Hospital readmissions are bad, very, very bad; at least according to CMS and other policymakers.  So how can we reduce them?  A new study carried at the National Bureau of Economic Research suggests that increasing home health visit length can influence the likelihood of a readmission.   (NBER Paper)  Home health is itself a growing, and relatively lucrative, part of health care.  The number of home health agencies has grown, along with utilization.  There is significant variation in the quality of home health care.  So it may not always achieve the goal of keeping patients from needing more expensive inpatient or skilled nursing care.  The authors used data from a large multi-state home health care provider to examine the relationship between visit length and readmission rate for the diseases that are subject hospitals to penalties under CMS’ readmission penalty program.  The researchers attempted to control for a variety of factors, such as patient health, the order of visits during a day and the typical amount of time spent by a specific home health worker.

The average home health visit lasts about 46 minutes, with a wide variation range, and there are about 14 visits per episode, also with a wide range.  Most are provided by nurses or physical therapists, who average about 4 visits per day.  24% of home health episodes of care are followed by a hospital readmission.  At a high level, the researhers found that spending one minute more than the average visit length resulted in 8% fewer readmissions, for those conditions subject to the CMS penalty program, and 5% fewer across all conditions.  That is a pretty amazing result, if accurate.  As might be expected, patients visited later in the provider’s work day have shorter visits, and therefore, greater likelihood of readmission.  And, also consistent with common sense, providers with a heavier workload tend to conduct shorter visits, also raising readmission rates.  But most interestingly, the entire impact of the effect on readmissions appears to be driven by part-time, as opposed to full-time, home health providers.  It may be that part-time workers simply aren’t as skilled.  Similarly, visit length by a nurse provider is more related to readmission risk than it is for a physical therapy provider.

If we assume that it is true that the quality and/or length of a home health visit can reduce readmissions, at least in Medicare there is often a disconnect between the financial costs and benefits of devoting more resources to longer visits.   Bundled or episode payments might solve this disconnect or common ownership between the hospital and home health agency.  This study also suggests that home health visits are best conducted by full-time nurse providers.  More research to understand why such a small change in time spent with a patient could have such a large impact on readmissions would also be helpful.