Improving Patient Outcomes and Reducing Readmissions

Home Health Care:

Home health care can improve your patients outcomes and quality of life.
Supports your team by caring for the most complex, chronically ill patients Educates your patients and their families to avoid unnecessary rehospitalizations Improves health and independence to help keep your patients happy and at home

Home health clinicians care for chronically ill patients where they spend most of their timeat home.
The home health care team serves as eyes and ears for the physician One-on-one time presents the opportunity to provide in-depth health coaching to improve patient compliance Multidisciplinary home-based care helps patients get the care they need where they need it

Advanced health care at home companies like Amedisys offer specialized multidisciplinary programs to treat the unique needs of the aging population.
Physical, occupational and speech therapy Balanced for Life fall prevention program for seniors Empowered for Life behavioral health program

Amedisys Care Transitions Coordination helps patients understand their plan of care, promoting a safe transition home after discharge.
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Care Coo
Thank you for trusting

CTC, hospital physicians and discharge team collaborate on care transition protocols

Care Coordination Report tracks progress and helps identify readmission trends
30 Day Hospital

CTC begins preparing for post -acute care coordination after referral to Amedisys but prior to hospital discharge

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Jan 1, 2012 to Mar 31, 2012

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Amedisys, Inc. Confidential

Amedisys performs in-home risk assessment and coordinates primary care follow-up appointment

CTC engages in health coaching with patient and caregivers

Welcome
DIscussION:

A. What was going on in your life before you arrived at the hospital? ________________________ ________________________ _______________ ________________________ ________________________ _______________ ________________________ ________________________ _______________ ________________________ ________________________ _______________ ________________________ ________________________ _______________ B. How were you feeling before you arrived? ________________________ ________________________ _______________ ________________________ ________________________ _______________ ________________________ ________________________ _______________ ________________________ ________________________ _______________ ________________________ ________________________ _______________

healthyliving
BR ID GE TO HE ALTH Y LIV IN G
s rso altl peThiHenah Record belongs to:

PLEDGE:

I understand that taking

healthy living
BRIDGE TO HEALTHY LIVING my medications correctly is important. as ___ Understand why I take are, my medications and how they work to help my conditions. ___ Understand the possible side effects and adverse reactions my medications

Therefore, I will:

___ Take all my medications ordered by my doctor.

___ Know what my medications and how to take as ordered. ___ Not make changes to

my medications without first discussing with my doctor.

Before I leave the hospital,

DIscHARGE cHEck LIsT

I will: ___ Understand any symptoms and/ or side effects that I need to watch for and whom to report them to.

___ Understand where I am going when I leave the hospital C. Did you happen to change and your daily routine? what will happen to me once I ________________________ ________________________ arrive. _______________ ________________________ ________________________ (NAME) ___ Have _______________ intments. the name and phone ________________________ medical appo ________________________ number of a person to contact record to ALL if : Take this _______________ ________________________ Remember I have questions after I leave ________________________ the _______________ hospital. ________________________ care ________________________ _______________ My home health tact is: er/con ___ Understand what my team memb medications are, how to obtain and : phone how to take.

___ Have a follow-up appointment scheduled with my doctor and transportation scheduled to get

me there.

___ Have any equipment

I need ordered and ready to be delivered when I arrive home.

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PERSONAL HEALTH RECORD
1

Amedisys provides health care at home to some of the most clinically complex patients in the health care system today.
Our average patient is 81 years old Takes more than 11 different medications Faces serious conditions like
- Heart failure - Stroke - Diabetes - Orthopedic recovery - Dementia - Depression - Pneumonia - Chronic pain - COPD - End-stage kidney failure - Wound care

To be eligible for home health care, a patient must meet specific criteria:
Medical necessity and skilled need
Does the patients diagnosis require skilled medical care? Is the need for home health care clinically appropriate?

Homebound status
Are absences from the home infrequent and of short duration? If the patient leaves the home, does it require a considerable and taxing effort? Has a doctor certified that the patient is homebound?

Download our Homebound Status Assessment to help determine if your patients could benefit from home health care.

At Amedisys, our referral process is streamlined to give you peace of mind and help keep you focused on your patients.
Contact your local care center or care transitions coordinatorwell handle the rest Our multidisciplinary team evaluates the needs of the patient and works with the patients physician to develop a plan of care to produce optimal outcomes

www.amedisys.com/locations

Learn more:
Understanding Homebound Status
A plain-language guide to this Medicare requirement. Download

Getting to Know CPO: A Guide to Care Plan Oversight

Physicians, nurse practitioners and physician assistants can be reimbursed for time spent overseeing their patients care. Download

For a consultation with an Amedisys home health care specialist, email CareTransitions@amedisys.com