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STAR Protocol

Home Health Agencies Partner to Reduce Hospital Readmission Rates

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  • Use an integrated approach to assess each patient at risk for readmission
  • Perform a comprehensive risk assessment with disease-specific indicators
  • Utilize evidence-based visit protocols for those patients at high-risk
  • Incorporate self-management tools into daily practice 
  • Reconcile medications and customize a Medication Action Plan (MAP) 
  • Monitor and manage the use of medications at all times
  • Activate fall prevention plan based on multi-factorial fall risk assessment
  • Assess and evaluate functional status and ability to safely remain at home
  • Promote follow-up with physicians within 7 to 10 days post-discharge
  • Instruct on identification of signs and symptoms of disease exacerbation
  • Assist the patient to maintain a Personal Health Record (PHR)
  • Conduct standardized depression screening (PHQ-2, PHQ-9, GDS)
  • Assess health literacy (determine reading comprehension in a medical context)
  • Administer Pneumonia vaccine, as indicated
  • Communicate high-risk status to multi-disciplinary team, patient and physicians
  • Include Tele-Health and Tele-Medicine in the Plan of Care, as indicated

Southeastern Home Health Services
Toll free: 866.285.2007 
Fax: 215.826.8300
Referral Fax: 1.855.620.7447