Reducing Hospitalizations in Home Health: A Key Strategy for HHVBP Success

One of the most significant quality measures in Home Health Value-Based Purchasing (HHVBP) is also one of the most challenging: reducing preventable hospitalizations.

Hospital admissions aren’t just disruptive to patients—they’re a red flag in CMS’s eyes. Under the HHVBP model, high rates of acute care hospitalizations (ACH) and emergency department use (ED Use Without Hospitalization) can severely impact your Total Performance Score (TPS) and result in reduced Medicare reimbursement.

If your agency is serious about improving HHVBP outcomes, hospitalization prevention must be a top priority.

Why Hospitalization Rates Matter in HHVBP

CMS measures your performance using claims-based data that tracks:📉 Acute Care Hospitalizations (ACH)🚑 Emergency Department Use Without Hospitalization🛏 Potentially Preventable Hospitalizations (PPH) During Stay🏠 Discharge to Community Post-Acute Care (DTC-PAC).

High numbers in these categories can lower your HHVBP score—even if your documentation and OASIS scores are excellent. That’s because hospitalizations are a clear indicator of avoidable gaps in care, communication, or planning.

Strategies to Reduce Hospitalizations in Home Health

✅ 1. Improve Early Risk Identification

The best way to prevent a hospitalization is to predict it before it happens. Build a risk screening process into your SOC and revisit it during recertifications.

🛠 Key Actions:

• Use evidence-based risk assessment tools

• Identify red flags for CHF, COPD, diabetes, and fall risk

• Flag high-risk patients in your EMR for care plan prioritization

✅ 2. Strengthen Care Coordination & Communication

Hospitalizations often occur due to breakdowns between providers, patients, and caregivers.

🛠 Key Actions:

• Assign case managers to high-risk patients

• Coordinate closely with PCPs, specialists, and family caregivers

• Conduct warm handoffs at admission and discharge

💡 Tip: Utilize HHCAHPS feedback to identify gaps in communication that may lead to ED visits.

✅ 3. Enhance Patient & Caregiver Education

Uninformed patients are more likely to panic and call 911. Agencies that teach self-monitoring, medication understanding, and red flag recognition see significantly lower hospitalization rates.

🛠 Key Actions:

• Use teach-back method during every visit

• Provide printed “what to do if” guides for common symptoms

• Educate caregivers on when to call the agency vs. going to the hospital

✅ 4. Monitor and Intervene Early

Set up a system to track patient changes in real time so you can intervene quickly when symptoms worsen.

🛠 Key Actions:

• Monitor daily visit notes for triggers (weight changes, dyspnea, pain scores)

• Establish rapid-response workflows for clinical follow-up

• Schedule check-in calls between visits for high-risk patients

Consultants can help you design escalation protocols and staff workflows to respond more efficiently.

✅ 5. Empower Staff Through HHVBP Training

Your clinicians are on the frontlines—they need to understand how their assessments and actions reduce hospitalizations and improve your agency’s score.

🛠 Key Actions:

• Train staff on HHVBP hospitalization measures

• Build in documentation prompts during SOC

• Use QAPI meetings to share real case reviews and outcomes

When staff understand their impact, they act with purpose—and patients stay out of the hospital.

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Conclusion

Reducing hospitalizations in home health isn’t just about patient safety—it’s about performance, reimbursement, and reputation. Under Home Health Value-Based Purchasing, every avoidable hospitalization affects your bottom line.

By combining early risk identification, patient education, and clinical coordination, your agency can improve care quality, boost your HHVBP score, and lead with confidence in a value-based world.

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💡 Need help building a hospitalization prevention program? Our Home Health Consulting team can help you design protocols, train staff, and align care with HHVBP success strategies.