In 2020, the worth of home-based care providers is often measured by their ability to avoid preventable hospital readmissions. As the U.S. health care industry continues to shift toward value-based care, that’s not likely to change any time soon.

One provider — Georgetown Home Care (GHC) — has made significant strides on this front. In fact, last year, GHC managed to achieve its lowest hospital readmission rates ever.

GHC is a Mid-Atlantic regional home care provider whose services lines include personal care, respite care, senior companionship services and senior transportation services. The company has 460 employees and serves Montgomery County, Prince George’s County, northern Virginia and Washington, D.C., where the company is based.

Last year, GHC’s hospital readmission rate checked in at 4.7%, compared to the national U.S. rate of 14.7%. Compared to 2018, the company saw a 29% drop year over year.

Additionally, on the skilled nursing side, GHC saw a 0% skilled nursing facility (SNF) rehospitalization rate. The national U.S. SNF rehospitalization rate was 22.3% last year.

Avoiding a one-size-fits-all approach has been important in GHC’s readmission efforts. This is especially true when it comes to individual cases in the home.

“Each of [our] patients are individuals, so you have to take a person-centric approach,” CEO John Bradshaw told Home Health Care News. “When you are sitting in their home, you need to look for things that may not necessarily be part of your procedure but could still potentially cause readmission. In other words, you want to make sure that you’re not just going out and checking the boxes off.”

Sometimes this means addressing social determinants of health, according to Bradshaw.

“When you get into the home, you sometimes find out that it’s not a particularly safe environment for the patient to be recovering in,” he said. “There could be a myriad of reasons, but you’ve got to have good resources to go back to the hospital and social workers and make sure they can address them.”

In general, the U.S. health care sector has been forced to recognize the impact that socioeconomic and environmental factors can have on a patient’s overall health. In-home care companies played a role in tackling these issues.

While lowering its own hospital readmission rates, GHC also had a hand in helping its hospital and SNF partners. One of these partners is Medstar Georgetown University Hospital.

Last year, GHC partnered with Medstar Georgetown University Hospital on a pilot where the company provided nurse practitioners to track the hospital’s patients after being discharged.

“They felt that their patients were going through things in the home that were sending them back into the hospital, and they couldn’t figure it out,” Bradshaw said. “We know the common causes of preventable hospital readmission and we can address those.”

Even with those common causes for preventable hospital readmission in mind, GHC wanted to approach the pilot by being cognizant of the unique conditions of Medstar Georgetown University Hospital patients.

“We wanted to work collaboratively with [Medstar Georgetown University Hospital] because we thought there may be some things specific to their patients, and the illness they were treating that we may need to address,” Bradshaw said.

Although Medstar Georgetown University Hospital and GHC’s partnership began last year, the latter had always been interested in pursuing this type of partnership with a hospital. The idea for this pilot program had been rolling around for almost seven years before it started, but finding the right partner was critical.

“The single biggest factor in lowering hospital readmissions is making sure you have a good partner,” Bradshaw said. “Are you partnering with the right hospital that has the right leadership in place and is motivated to effect a good outcome?”

In other words, a hospital partner that may be willing to form the kind of partnership that GHC and Medstar Georgetown University Hospital have, but isn’t willing to pull their weight could create roadblocks.

“If you have a hospital that says, ‘You just figure it out,’ then you’re probably never really going to get anywhere,” Bradshaw said. “We were lucky to work with Medstar Georgetown University Hospital because their leadership was a driver in helping us have good outcomes.”

Having a well-trained staff in and out of the field is also a key factor in lowering hospital readmissions, according to Bradshaw.

“Does everybody understand what the goals are,” he said. “If you are going to create a program like this, you not only have to train your nurse practitioners but your community liaisons, caregivers and everyone that is interacting with the leadership at the hospital. This has to happen at every level.”

Another key factor is helping seniors gain plan-of-care literacy, which can have a major impact on outcomes down the road.

“Think about a situation where a senior citizen has fallen and had hip replacement surgery,” Bradshaw said. “The hospital determined that it’s appropriate for her to go home and recuperate. When she has just been discharged, it’s already a whirlwind, a complicated process will be explained to her when she’s not at her best. Having a nurse practitioner in the home explaining everything to her is effective.”

Though GHC’s initial pilot has ended, Medstar Georgetown University Hospital has continued the partnership which continues to yield similar hospital readmission rates as the original program, according to Bradshaw.