Signify Health has become an unexpected advocate for home health since it launched its Transition to Home solution nearly six months ago. Transition to Home is a clinical and social support program that helps hospitals transition Medicare patients to their homes for 90 days after a hospital stay.

Marc Rothman, M.D.

“You would be surprised how many people have home health ordered for them, but that doesn’t actually happen for various reasons,” Signify Health Chief Medical Officer Marc Rothman, M.D., told McKight’s Home Care Daily.

Signify Health — a Dallas-based company that leverages analytics and technology for healthcare provider networks — has activated Transition to Home in 50 hospitals in a dozen states. So far, the program has helped 3,000 patients move from hospital to home.

Signify Health launched Transition to Home in February to help clinically-integrated networks (CINs) and accountable care organizations (ACOs) reduce costly hospital readmissions. The program engages with patients through telephone and in-person visits to improve outcomes by helping manage medications, addressing social determinants of health and overseeing other health issues.

Rothman said home healthcare often plays an enormous role in reducing readmissions, but older patients sometimes decline it because they don’t realize Medicare will cover the cost or they don’t want care providers inside their homes.

“Often we find patients need a little bit of encouragement to activate the home health services, which wouldn’t have been ordered if they were not needed,” Rothman said. “So we end up becoming the advocate for the home health agency to make sure they can activate the services that were ordered like physical therapy, occupational therapy or speech therapy.”

Rothman said there have been cases where Transition to Home has recommended the recertification of home health care for patients in an effort to avoid possible hospital readmissions down the road.

The Centers for Medicare and Medicaid Services (CMS) said nearly 1 in 5  fee-for-service Medicare patients returns to the hospital within 30 days of discharge. CMS estimated hospital readmissions cost Medicare approximately $26 billion annually, $17 billion of which is potentially avoidable. CMS has been aiming to reduce that through hospital readmission reduction programs, shared savings programs and quality improvement organizations.