Alta Home Care Readmission Prevention Case Study

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Alta Home Care takes extreme measures to prevent avoidable readmissions to the hospital.

This case study illustrates a real experience to demonstrate how Alta is one of the top home care agencies focusing on keeping their clients out of the hospital and in the comfort of their own homes.

Client Condition:

On November 27, 2013 Alta Home Care received a referral from St. Jude Medical Center in Fullerton. The client was a female age 79 with a recent hip fracture resulting in surgery. The client was non-weight bearing due to the surgery and also suffered from CHF which resulted in a heart transplant 10 years prior. Client was alert and oriented at the initial evaluation with Alta Home Care. St. Jude’s case manager recommended live-in care to be arranged prior to discharge home. Case Management also ordered in-home PT and required caregiver rehabilitation training prior to discharge.

Care Plan:

The client’s family requested to interview Alta’s caregivers prior to discharge to ensure “a good fit” for the client. Alta Home Care’s staffing database allowed our staffing coordinator and her team to quickly and efficiently identify three (3) qualified caregivers for the family to interview. A personal confirmation call was made to the client’s family with the date, time, and names of the caregivers for the interviews. The interviews took place on December 2nd. The family selected two (2) caregivers to provide 24 hour live-in care for the client.

Rehabilitation training was held on December 4th at St. Jude and was provided by St. Jude PT staff. Alta’s caregivers completed rehab exercise training and on December 5th the client was released home with 24-hour live in care.

Post Discharge Care:

Alta Home Care has continued to provide care with the same caregivers guaranteeing consistent and quality care for the client. Alta’s Care Manager maintains direct communication with the family to ensure the client’s needs are being met, to monitor client health status, and to confirm that the client is meeting the care plan goals.

Alta’s caregivers also communicate with the office and express any concerns or change of condition of the client. On February 6th, the client was told by her PCP that she no longer needs live in care. On February 8th, the client’s caregiver called the office to inform the Care Manager that the client wasn't feeling well. Alta’s staffing team was able to immediately staff a qualified caregiver and help keep the client out of hospital.

Alta Home Care also employs a LVN Case Manager who makes home visits to their clients. She will asses our clients' clinical needs and will work with the family, the PCP, and other medical providers to arrange for additional care as needed.

Rehabilitation training by St. Jude coupled with Alta’s ability to staff experienced and compassionate caregivers provided the best possible recovery outcomes for the client. Most importantly, the client has not returned to the hospital and is able stay in the comfort of her own home. The family has extended service until February 20th, when we will reevaluate the client’s care needs.

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Adrienne Zielasko

+1 714-334-2447
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