Ascension’s Blueprint for Seamless Home Health Integration

Ascension, a large non-profit health system operating across 17 states and Washington, D.C., with approximately 97,000 employees and a network of 90 wholly-owned hospitals plus 29 partnerships, is at the forefront of this change. The organization, which also operates 22 senior living facilities, prioritizes home health providers demonstrating exceptional responsiveness – ideally, in-home visits within 24 hours of referral – alongside the capacity to address the full spectrum of a patient’s ordered care plan and consistently high acceptance rates.

“We’re working incredibly hard to expedite patient discharge, ensuring they transition to the most appropriate, lowest-cost, and comfortable care setting – and for many, that’s their home,” explains Lisa Musgrave, Senior Vice President of Post-Acute and At-Home Services at Ascension. “We aim to support their individual goals, understand their caregiver dynamics, assess their home environment, and provide everything they need for a swift and successful return to their lives. It’s about getting them back to their routines, their families, and their pets.”

The Criticality of Immediate Response Times

Ascension’s expectations regarding referral acceptance are particularly stringent. While a two-hour service level agreement (SLA) exists, Musgrave’s team actively seeks partners capable of responding within 7-10 minutes. This emphasis on speed isn’t merely about efficiency; it’s directly linked to preventing hospital readmissions and optimizing patient outcomes.

However, speed is only half the equation. Agencies must also deliver on their commitments. “When we send a referral, we need a definitive answer – yes or no. And if you say yes, you must follow through,” Musgrave stresses. “Too often, we hear initial acceptance followed by delays of four or five days. Our patients require attention today and tomorrow. If you can’t provide that level of immediate care, it’s better to decline the referral upfront.”

Ascension’s ideal acceptance rate exceeds 85%, a benchmark significantly higher than the industry average, which Musgrave estimates to be below 60%. A persistent challenge lies in agencies accepting referrals only to later retract their commitment, disrupting the patient-choice process and creating logistical bottlenecks. This has led to case managers distributing referrals to multiple agencies simultaneously, resulting in a fragmented and inefficient system.

Addressing Discipline Gaps and Ensuring Comprehensive Care

Musgrave highlights the importance of fulfilling all ordered disciplines. “We frequently encounter situations where agencies request the removal of specific services, which compromises patient care. As an industry, we need to ensure that if a discipline is prescribed, it’s provided. There must be a clear clinical rationale for every component of the care plan.”

To facilitate smoother transitions, Ascension has established a joint venture with Compassus and implemented a dedicated liaison program. These liaisons work directly with hospital discharge teams and case managers, proactively preparing for patient arrivals in home health or hospice and engaging in conversations with patients and their families to ensure informed decision-making.

This proactive approach involves discussing the suitability of home health or hospice, presenting in-network options, assessing the home environment, and securing a reserved spot for the patient with their chosen agency. The result is a more streamlined and timely transition, minimizing delays and maximizing patient satisfaction.

Ascension’s broader strategy centers on shifting care from hospital settings to more cost-effective and patient-centered environments. The health system is actively investing in ambulatory surgery centers, outpatient rehabilitation facilities, and home care services, recognizing that reducing the total cost of care requires a fundamental shift in delivery models. The American Health Insurance Plans (AHIP) also highlights the growing importance of home-based care in reducing healthcare costs.

What innovative strategies are home health agencies employing to meet these evolving demands? And how can technology be leveraged to improve referral response times and care coordination?

Frequently Asked Questions About Hospital-Home Health Partnerships

• What is the biggest challenge home health agencies face when partnering with hospital systems?

  The most significant challenge is consistently meeting the demand for rapid response times and maintaining high acceptance rates while ensuring adequate staffing and resource allocation.

• How important is communication in a successful hospital-home health partnership?

  Communication is absolutely critical. Agencies must provide timely and transparent updates regarding referral acceptance, potential challenges, and any necessary modifications to the care plan.

• What acceptance rate do hospital systems typically expect from home health providers?

  While industry averages are lower, leading health systems like Ascension aim for acceptance rates exceeding 85% to ensure patients receive timely and appropriate care.

• How are hospital systems working to improve the home health referral process?

  Many systems are implementing liaison programs and leveraging technology to streamline communication, proactively prepare for patient discharges, and facilitate informed decision-making.

• What role does technology play in enhancing hospital-home health collaboration?

  Technology can automate referral processes, improve communication, enable remote patient monitoring, and facilitate data sharing, ultimately leading to better care coordination and outcomes. HIMSS provides resources on digital health innovation.