Check in with patients post-discharge for success on difficult DTC measure

 

The claims-based measure is already publicly reported on Care Compare. Beginning with 2025 results under Home Health Value-Based Purchasing (HHVBP), DTC replaces the OASIS-based discharge measure when calculating payment adjustments. 

 

The challenge for agencies is that the old HHVBP measure just reflected what was listed on the discharge OASIS. For the new claims-based measure, agencies will see their score impacted if the patient is hospitalized or dies within the 31 days post-discharge, notes Annette Lee, CEO and founder of Provider Insights of Des Moines, Iowa.

 

And successful discharge is more important with the new measure — accounting for 9.0% of the total score under HHVBP, compared to 5.8% for the previous discharge item.

 

“It’s not getting much attention, but it should be,” she says. Some agencies have been surprised that they need to keep up with the patient’s status after discharge.

 

It’s a challenge for agencies that struggle to move the needle on hospitalization rates while seeing the patient, much less after discharge, Lee notes. 

 

“We can’t stop a hospitalization if they’re needed, but we can reduce hospitalizations — just like when they’re on service with us,” she says. “We need to give them good tools and keep those channels of communication open.”

 

It’s a different mindset for a lot of folks that we should be encouraging the patient to contact us — after discharge — whenever it would be warranted, Lee says.  

 

“We can then help them get in touch with their doctor,” she notes. “And, if it’s something that could warrant a readmission, we’ll get in touch with the doctor and circle back.”

 

This requires agencies to be proactive and set up a schedule of routine calls to the patient to check in on any changes in condition or other updates, Lee says.

 

She suggests calling two days after discharge and then weekly thereafter. A script Lee provides to agencies includes questions about ER or doctor visits, along with questions about issues with pain or getting around the house. 

 

The size of an agency, staff roles and individual bandwidth is going to determine who would make these calls. Usually, it’s the case manager making the calls in the car between visits. 

 

At larger organizations, it would be someone in the office, Lee notes. That could be a nurse, but someone in intake could also make the calls, she says. “They’re trained and they’ve got good customer service skills.” 

 

One agency has a “welcome department” that manages patients discharge from the hospital into home health. This kind of department can make these post-discharge calls, as well. They’ve already talked with the patient as they were transitioning between providers, Lee notes, and this is the last transition of their home health stay.

 

There are some agencies that might struggle to justify the effort for a modest adjustment in HHVBP reimbursement, but the benefits go beyond one score.  

 

One agency has marketers making these post-discharge in the event the patient needs a readmission. Note: Agencies want to keep the calendar in mind when it comes to readmissions. If the patient was initially discharged early in their final 30-day period, that could impact payment for a readmission in that same 30-day period.

 

Another added benefit of these extra touches is that it’s a chance to refresh the patient’s memory about their experience ahead of the Home Health CAHPS survey. 

 

“I always talk about the layering of these measures,” Lee says. “If you get some good things going, it’s going to be like a domino effect.” 

 

Connecting with the patient post-discharge is going to catch many issues before an ER visit, but agencies already outperforming on DTC are planning for a successful discharge beginning at the start of care, Lee notes. 

 

“We need to have a longer runway on the discharge planning,” she says. “We should be preparing the patient and not just giving them two days notice — and sometimes agencies fail to even do that.”

 

For example, a conversation at the start of care around the patient’s goals, in the end, is really about expectations at discharge. “Having that longer runway, starting these discussions  transparently upfront, and then the following through — that’s something the average agency might not be doing,” Lee says.

 

“Following through” includes sound case management practices, with each visit building on the last based on the patient’s particular diagnosis. By discharge, the patient has learned what to expect and, importantly, received clear guidance on when to call the agency with questions. Red/Yellow/Green tools are a great way to reinforce this message and help the patient recognize symptoms.

 

Other considerations around the DTC score: 

 

Measure progress. Data will be a challenge for agencies. Preview reports for Care Compare only update claims-based measures in July each year, ahead of the annual update to public reporting in October. 

 

HHVBP interim performance reports are updated quarterly, but CMS notes that these reports only include the most recent available 12 months of data, whereas your final results on the DTC measure are based on two full calendar years of data. 

 

To keep up with your own progress without the delay of waiting for CMS figures, track your post-discharge calls. You can log patient incidents and track your DTC success over time, Lee notes.

 

Contact isn’t a HIPAA violation. One question that Lee has received about post-discharge calls is HIPAA compliance. She notes that the Office of Inspector General has long held the position that follow-up calls are a part of good patient care and successful discharge.  

 

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