Growing numbers of patients need ongoing professional medical services when they return home to reduce hospital readmission. Johns Hopkins Care at Home and Johns Hopkins Care at Home - Potomac help patients to regain and retain their level of function and independently manage their health care needs. With a coordinated approach that stresses personalized care, the team works closely with the physician, the patient and family members to plan, review progress and make adjustments to the plan of care.

What are these measures?

The Johns Hopkins Care at Home and Johns Hopkins Care at Home - Potomac provide health services, such as skilled nursing, physical therapy and speech therapy, for patients in the comfort of their own home. Care Compare is a resource, created through the efforts of the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, which allows consumers to compare home health agency performance in a variety of ways, including its own star rating measures. Care Compare shows how often each home health agency used best practices when caring for its patients and whether patients improved in certain important areas of care.

The quality of patient care star rating is a quarterly summary measure of agency performance based on how well a home health agency performs on nine of the individual quality measures reported on Medicare’s Care Compare. These measures were selected to give a general overview of agency performance on measures that apply to the most people.

To have a quality of patient care star rating computed, home health agencies must have reported data for five of the nine measures used in the star rating calculation.

Why is this important?

Quality home care is a critical component to ensure patients receive necessary treatment after a hospital stay or for medical conditions that may require it. Home care providers train caregivers and engage case managers, community physicians, and insurance providers to create wrap-around care of the patient. By engaging in timely intervention of care, fall prevention interventions, medication monitoring and education, and remote patient monitoring for certain disease pathways, home care providers can reduce the risk of hospital readmission.

Prospective home health care patients and families can use Home Health Compare results to objectively see how well health agencies care for their patients, how often each agency used best practices when caring for its patients, whether patients improved in certain important areas of care, and what other patients said about their recent home health care experience to help determine which home care group is best for them.

What is Johns Hopkins Medicine doing to continue to improve?

Collaborate and Coordinate Care

Approximately 85 percent of Johns Hopkins Care at Home and Johns Hopkins Care at Home - Potomac patients are coming from a hospital setting. Prior to discharge, home care coordinators, who are strategically placed at each Johns Hopkins Medicine hospital, coordinate with home care providers, hospital care teams, patients and their caregivers to ensure that patients will begin to receive care within 48 hours.

Communicating Clearly with Patients

Home care staff provide patients with a patient-friendly medication list to teach patients and/or caregivers how to manage medication information. The team uses this document to review with patients each of their medications and ensure they are taking the medications as prescribed. This assists them in transitioning into managing their own care, as soon as possible. Home care staff use the patient-friendly medication list as a tool to review and discuss medication purpose, dose, how often to take and side effects.

Comprehensive education and communication help patients learn to manage themselves when caregivers aren’t there. This empowers patients to regain and retain their level of independence.

Creating a Safe Home Environment

Home care rehabilitation staff members execute a comprehensive assessment of each patient’s needs and home environment to create an individualized care plan with instructions on a home exercise plan. Patients’ living environments are assessed and staff may make recommendations to minimize fall risk.

Frontline Perspective

As a home care therapist, Mindy Nadel says there is no cookie-cutter approach and instead provides highly specialized care to each of her patients.

Mindy Nadel
Physical Therapist, Johns Hopkins Care at Home - Potomac

“The best part of my job as a physical therapist is taking care of the patients and helping them reach their highest potential. My first visit in the home is a thorough evaluation to ensure that every aspect of care is covered: an in-depth home safety assessment, an evaluation of the patient’s functional mobility, strength and balance, pain and edema management, durable medical equipment needs, and an evaluation of any applicable surgical site or wound care. I can then apply exactly what each patient needs based on his or her environment and develop a personalized home exercise program. I always ask my patients what their goals are and then work with them to problem-solve, improve their functional status, and help them to feel the best they possibly can.

One of my favorite patients was an elderly lady who had fallen and fractured her hip and wrist. Because of her advanced age, she was not a surgical candidate to repair her hip and was not allowed to walk. When she returned home after her hospital stay, I worked with her and her caregivers on transfer training from her hospital bed to her wheelchair. A few months later, her orthopaedist prescribed home care again to begin gait training. She began to improve, from being bedridden to wheelchair bound, and eventually to walking again, all while living in her own home. She had a wonderful spirit and attitude. It is so rewarding to help my patients and encourage them to reach their full potential while discovering what they are capable of.”

How can patients and families support safety?

Resources

For more information

• Johns Hopkins Care at Home
• Johns Hopkins Care at Home - Potomac
• Centers for Medicare and Medicaid Services Care Compare

Patient Resources

• Types of Home Health Care Services
• Knowing When It's Time for In-Home Help
• AHRQ’s Taking Care of Myself: A Guide for When I Leave the Hospital Guide

Quality and Safety Performance During COVID-19

The organization’s quality and safety performance may have been impacted by the COVID-19 pandemic. We would urge patients to consider more recent performance in combination with historical performance. Patients may benefit from discussing with their healthcare provider the disruptions COVID-19 may have caused on quality and safety of care.

See how Johns Hopkins Medicine prioritizes safety during the COVID-19 pandemic.