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For Health Providers

How Swan Home Health Care Can Help You and Your Patients?

Nationally, approximately 1 in 5 Medicare beneficiaries experience a re-hospitalization within 30-days post-acute discharge and estimates show that 76% of these readmissions may be preventable. In an effort to improve care coordination and chronic care management, Swan Home Health Care  is committed to working collaboratively with other healthcare providers, consumers and community service providers in our community.

Because older patients with chronic illness often require care from multiple health care professionals in a variety of settings, communication and care coordination among providers, patients and their informal caregivers is critical. The Home Care industry is an integral part of the care team managing patients outside of the traditional setting.

Home care providers are a vital part of the care transitions coordination of care. By providing care for those unable to leave their homes, home care agencies work to help individuals remain as self-sufficient as possible in their own homes, thus, avoiding institutional long-term care. Divers in its makeup, home care includes nursing care as well as other services, like physical and occupational therapy, speech-language therapy, and medical social services and personal care services.

Home care agencies are in an ideal position to assist patients, family caregivers, and the cross-continuum team in a successful transition out of the hospital that achieves clinical stability and improves patient outcomes. Excellent and proactive intervention by home care agency staff at the point of a transition for a patient into home care is a significant strategy to reduce avoidable rehospitalizations.

By working together, we have the opportunity to improve rehospitalization rates – and do the right thing for patients.

Swan Home Health Care follows Medicare criteria for admission to our services. This criterion is as follows:
  • We accept patients for services based on an expectation that the patient needs can be met and that continuity of care can be provided. Patients may be self referred or referred by physician, discharge planner, friend or family member.

  • The patient/client and if necessary, a competent caregiver, must be willing to be trained and able to participate in the plan of care, comply with the therapeutic regimen and agree that the patient/client should receive care at home. If the patient requires shift care, there needs to be a family member or a trained and competent caregiver to assume care in the event the agency is unable to staff a shift.

  • Both the patient/client and the physician (if applicable) must understand the scope of home care services and agree to work cooperatively with the agency. The agency must have adequate and qualified personnel and resources to provide the services required; this includes the ability to provide care to patients in all age groups and nationalities with language needs considered.

  • The physical facilities and resources in the patient’s residence, school and/or community environments must be adequate for proper and safe care. For a private duty shift case:

    • Physical facilities and resources in the patient’s home, school, and/or community environments will be adequate for proper and safe care to the client and staff member.

    • The patient has a family member or significant other trained and competent to assume care in the event the agency is unable to staff a shift.

    • The patient/family member agrees to keep privately owned medical and emergency equipment appropriately calibrated and maintained for safe and accurate delivery of nursing care.

  • There must be a plan to meet medical emergencies.

  • There is a reasonable expectation that payment will be received, or there is a payment source (private pay, insurance, MediCal, Medicare, etc.)

  • Authorization number (if applicable) must be obtained by us before initiating services.

  • The patient resides in the geographical area served by the agency.

  • If all parties agree that the patient is an acceptable candidate for services a more complete evaluation will occur. The subsequent evaluation will intensively consider the following admission criteria.

    • Current medical status including:

      • Patient’s current diagnosis(es) and medical problems.

      • Patient’s current medical history.

      • Patient’s past medical history.

      • Pertinent physical findings, including any physical limitations.

      • Pertinent laboratory test results.

        • For infusion cases:

          • Availability of suitable venous access, where appropriate.

          • Appropriateness of the dose, route, and frequency of administration for the patient.

          • Appropriateness of the choice of drug(s) chosen for the patient

  • Criteria for admission under Medicare home health services also includes:

    • The patient must be homebound as required by the payer.

    • The patient must require skilled qualifying services.

    • The care needed must be intermittent (part time.)

    • The care must be a medical necessity (must be under the care of a physician.)

    • The care must be reasonable and necessary.

    • There is no duplication of services.

We cannot accept for service any patient known to be in an unsafe environment (either for patient/client or agency staff) or any case in which specialized care is required and specialty-prepared staff are not available. If the patient/client does not meet admission criteria, the patient/client is referred to alternate services and the referral source and the physician (if applicable) are notified.

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