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Post-Acute Transitional Services: Safety in Home-Based Care Programs

Vanessa McElroy, MSN, PHN, ACM-RN, IQCI, Ron Billano Ordona, DNP, FNP-BC, GS-C, and Deb Bakerjian, PhD, APRN, FAAN, FAANP, FGSA | April 27, 2022
View more articles from the same authors.


Transition of care is the period of time when patients move between one health care unit to another that are in different locations and offer different levels of care. Post-acute transitional care services involve discharging patients with ongoing complex care needs from the hospital to a home-based or community care environment. This period carries a high risk of medical errors and adverse events due to fragmented communication including failure to complete safe handoffs and the need to integrate between a number of organizations and home-based and community health care providers.1,2 Approximately one in five hospitalized patients are readmitted within 30 days and a third of patients are readmitted in 90 days.3,4 A recent systematic review of 54 moderate to high-quality studies found that about half of older adult patients transitioning from the hospital to community settings were affected by at least one medical error and 20% were affected by one or more adverse events.1 Patients with low socioeconomic status are at particularly high risk for poor outcomes such as medication errors, injuries, and higher hospital readmission rates.5,6 An important, but underemphasized, area of concern in home-based primary care is diagnostic error, including missed diagnosis, delayed diagnosis, and wrong diagnoses.7 While this has been shown to be problematic in office-based primary care,8-10 it has not been studied in home based primary care settings.

Home-based care programs can accept patients discharged from hospitals either in their home or an assisted living or residential care facility. Home-based care, as defined by the World Health Organization (WHO), is a series of services provided to people in their homes that may include physical, psychosocial, or palliative care activities.11 These services may comprise 24-hour support or intermittent assistance for frail older adults, patients with disabilities, or those in need of prolonged post-hospitalization care.12 There have been reports of a number of patient safety challenges associated with home-based care such as ineffective handoffs, limitations in clinical information, and medication errors.2 Despite those challenges, some studies have shown that home-based care can provide patients an effective, safe, and appropriate continuation of medical services beyond the traditional care provided within hospital and clinic walls if evidence-based practices are followed.13 In fact, a group of stakeholders has developed a three-category quality model (provider and practice activities; provider characteristics; and patient, provider, and caregiver outcomes) with 10 domains and 49 standards of care.14 Unfortunately, as yet, little research has been done using this framework.

There are three main types of home-based care categorized by the type of services provided and the patient’s functional and medical goals of care:

  1. Custodial Care constitutes the largest segment of home-based care; it is estimated that more than 53 million (21.3%) Americans were informal caregivers to either a child or adult in 2020; over half of these provide care to 5.5 million adults, 3.6 million of whom have dementia.15,16 Informal caregivers may be family or friends or trained paid caregivers.
  2. Home Health Agencies provide care by employing visiting licensed nurses, home health aides, and physical, occupational, and speech therapists in the patient’s place of living.
  3. Home-Based Primary Care is provided by physicians or advanced practice providers including nurse practitioners, physician assistants, and pharmacists.

The interprofessional team care provided in these programs seeks to ensure patient safety, while promoting patient independence, and has an overarching goal of reducing unnecessary hospitalization or emergency department (ED) visits and reducing the cost of care. Home-based care focuses the majority of services toward chronically ill or functionally frail patients who are also at higher risk for patient safety events such as medication errors, falls, and other adverse events. The spectrum of home-based care ranges from low acuity, which is chronic care with little or no provider involvement to high-acuity acute care with high provider involvement.

This primer describes the patient safety issues and approaches to care associated with Home Health Agencies (HHAs) and other home-based programs. Recommendations for best practices designed to optimize care and reduce adverse events are reviewed.

Formal Home-Based Care Programs

Home Health Agency Services

The largest providers of home-based care are HHAs that provide skilled and unskilled care in patient’s homes. HHA services are defined as medical and personal care provided by professional nursing and rehabilitation staff and non-professional home health aides within the patient’s own place of living.17 A patient must meet these three essential criteria in order to receive care via home health services:

  1. be under a provider’s care,
  2. have a face-to-face patient and care provider encounter within the 90 days prior to the start of care or within 30 days after the start of care, and
  3. be considered homebound.

The Centers for Medicare & Medicaid Services (CMS) defines homebound as being confined to the home due to an illness or injury. To be considered homebound, a patient must meet one of two conditions: (1) require some type of supportive device and/or the assistance of another person to leave their home; or (2) leaving their home is medically contraindicated. Once the patient meets either of these conditions, the provider must certify two additional criteria: (1) leaving home would require considerable and taxing effort; and (2) leaving home would be unusually burdensome for the patient.2

Moreover, the provider must also certify that the patient needs intermittent complex care that can only be provided by qualified licensed nurse or therapy clinicians, and that the qualifying condition is expected to improve in a reasonable time.

Referrals to an HHA are made solely at the discretion of a provider, resulting in substantial variability in referral practices that may result in some patients not receiving needed home health services.18 This problem can be resolved with more widespread use of clinical assessment tools that incorporate relevant clinical and nonclinical information (e.g., caregiver status). Use of these standardized tools may support more standardized, efficient, and evidence-based referral processes and reduce the risk for adverse events.18

In 2020, there were 11,221 HHAs, and almost 81% were for-profit.19 For-profit HHAs have been reported to have higher costs ($4,827 compared with $4,075 per episode) and lower quality compared with not-for-profit agencies,20 particularly pertaining to rehospitalization rates.21 To ensure quality of care and patient safety, HHAs are nationally accredited by one of three accrediting bodies (The Joint Commission, Accreditation Commission for Health Care, or the Community Health Accreditation Program22) and surveyed by the accrediting agency and the state agency approximately every three years.23 HHAs must be certified by CMS before they can accept Medicare patients. Each HHA submits a standardized comprehensive set of patient care data (Outcome and Assessment Information Set or OASIS) to meet quality reporting requirements to CMS; these data are reported publicly on the Care Compare website. Ratings include items such as the extent to which patients improve overall, whether they were taught about their medications or had unplanned visits to the ED, were admitted or readmitted to the hospital, or remained in the community after discharge from home health.

One study of over 17 million hospitalizations comparing patient outcomes between patients discharged to skilled nursing homes versus home health found a higher 30-day readmission rate in patients discharged to home health, but at lower cost of care with no differences in functional outcomes or mortality.24 Patients discharged from hospitals to HHA care have accounted for 25% of hospital readmissions associated with infections.25,26 For example, in a study of 28,205 home health care patients with urinary catheters, the lack of appropriate policies resulted in a 21% higher probability of hospital transfer due to urinary tract infections.27 Another study found that HHAs that failed to provide required family caregiver training resulted in almost twice the number of acute care hospitalizations.28 Similarly, an older study of hospital readmissions of patients after hip fracture, chronic obstructive pulmonary disease (COPD), pneumonia, stroke, and congestive heart failure (CHF), found that those patients were being readmitted at rates ranging from 12%-23% at 30 days and 18-34% at 60 days. These readmissions were associated with wide geographic variations in practice styles, local regulations, and availability of services.29 A recent systematic review found that patients with heart failure had the highest rate of readmissions due to exacerbations of symptoms. However, other risk factors for readmission included older age, Black race, poor overall health status, severity of illness, more co-morbidities, living alone, fewer visits from home health aides, and other risks.30 These findings demonstrate just some of the risks for adverse events associated with patients receiving home health care.

There have been several efforts to improve home health care, particularly focused on improving value, greater team-based care, more effective coordination of care across health care settings, and better focus on the use of technology and population health.31 For example, for the past several years, CMS conducted a pilot Home Health Value-Based Purchasing (HHVBP) program and on January 1, 2022, began the Expanded HHVBP model.32 The purpose of the program is to incentivize HHAs to transition from volume-based care toward incentivizing higher quality of care. A study targeted at patient safety and adverse events in home care of older persons with diabetes reported higher readmissions due to the patient’s reduced ability to self-care (associated with functional decline or cognitive impairment), suboptimal approach to care by home care agencies (failure to educate and train patients to care for themselves), and failure to conduct annual reviews to look for decline in patients’ conditions.33 Studies have shown that higher registered nurse staffing and employing team-based approaches, including integrated practice in home care, have shown promise in improving patient outcomes.34-37

Home-Based Primary Care

Home-Based Primary Care (HBPC) was originally designed for veterans who need team-based, in-home support for ongoing diseases and illnesses that affect their health and daily activities.38 Veterans who meet these criteria usually have difficulty making and keeping clinic visits because of the severity of their conditions and are often homebound. The HBPC program has now expanded beyond veterans into modern-day house call programs. The “house call” concept started in the 1930s, when it was common for physicians to make home visits to patients; in fact, 40% of all healthcare in the U.S. was provided in the home.

The modern-day “house call” delivers primary care only to the most medically complex homebound or home-limited patients, those who typically have difficulty attaining follow-up care, perpetuating the cycle of poor health management at high cost.39 The advent and rapid development of health information technology has been a driver of the resurgence of home-based care. Electronic medical records allow access to patient charts virtually anywhere. Portable x-ray and ultrasound equipment is readily available, and a smartphone can function as an electrocardiogram, an ultrasound console,40 a portal to medical references (such as textbooks and drug databases41), and a means of transmitting paperwork (with remote scanning and printing capabilities41). In recent years, an influx of nurse practitioners (NPs) has facilitated the growth of HBPC,43,44 although HBPC practices most often employ a multidisciplinary approach. Many types of Medicare-covered services can be provided during HBPC visits, including evaluation and management of patients, chronic care management, transitional care management, Medicare annual wellness “check-ups,” and advance care planning. A systematic review conducted in 2016 examined HBPC of adults with serious illness and found that HBPC was associated with fewer hospitalizations and length of stay and that frail or sicker patients are more likely to benefit from HBPC services.45

Independence at Home

Independence at Home (IAH) is a specific type of home-based care service aimed at frail, homebound older adults that started as a CMS Innovation Center demonstration project.46 As part of the IAH Demonstration, the CMS Innovation Center worked with select medical practices around the country to test the effectiveness of delivering comprehensive primary care services to Medicare beneficiaries with multiple chronic conditions in their homes.47 Practices participating in the project that provide high-quality care while reducing costs could be rewarded through the IAH Demonstration. IAH services target fee-for-service beneficiaries with at least two chronic conditions, and who need assistance with two activities of daily living, have been hospitalized in the previous 12 months, and who have not been in long-term care or hospice at the time of enrollment. Participating practices make in-home visits tailored to individual patients’ needs and coordinate their care.

The Commonwealth Fund report, “An Overview of Home-Based Primary Care: Learning from the Field,” identifies salient points and lessons learned from home-based primary care.48 Of note, they report that less than 12% of homebound persons receive any primary care services and that even if those patients could get to the office, traditional office visits that focus on single complaints would not adequately serve this population. Providing care with interdisciplinary teams, longer and more comprehensive appointments, integration of behavioral health and social support, and better care coordination through regular team meetings, are some of the best practices in the IAH model, which incentivizes practices based on a share of cost savings.

While there have been some positive outcomes over the first five years of the IAH Demonstration, there has been little evidence to support the hypothesis that IAH payment incentives reduced Medicare spending or significantly improved quality of care for beneficiaries with chronic illness and functional limitations. In Year 5, the payment incentive was associated with lower Medicare expenditures, but these results were driven by one site that soon thereafter stopped providing home-based primary care.48 The most recent report available (2019) demonstrated only a $41 reduction per beneficiary per month in Year 6, which was not statistically significant.49 Unfortunately, there was no evidence that IAH reduced ED visits or hospital admissions, and only six of nine practices met required standards for quality and only then for half of the required measures. Despite these results, there are some population subgroups that appear to benefit from IAH services. Among these subgroups are individuals who would benefit from improved access to regular primary care and those near end of life who would benefit from less undesired aggressive care. Over the years, the program has had multiple extensions, the latest of which was in December of 2020, for an additional three years; it is scheduled to end in 2023 unless reauthorized.

Hospital at Home

Hospital at Home (HaH) is an innovative care model that allows health care organizations to provide high-quality hospital-level care to acutely ill, mostly older, adults in their homes. HaH is designed to improve outcomes, decrease the length of stay, enhance patient experience, and reduce health care costs, which can be 19% to 30% less than for traditional inpatient care.50 HaH fully substitutes for acute hospital care. The program has been implemented at numerous sites around the U.S. by Veterans Administration (VA) hospitals, health care systems, home care providers, and managed care programs. HaH programs differ from more traditional home health services; in HAH, patients must qualify for hospital-level service and require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis in the home. Hospital care at home services provide health care to acutely ill patients in their homes by using methods that include telehealth, remote monitoring, and regular in-person visits by nurses.15

According to DeCherrie and colleagues, HaH has been associated with higher quality, improved patient safety, improved patient and family experience of care, and reduced cost in appropriately selected patients.51 A 2018 case-controlled study of the HaH model with a control group of similar patients that did not select HaH services found that HaH patients had shorter length of stay, lower odds of hospital or ED readmission, and better patient experience of care.52 However, other studies did not find lower readmission rates,53 have shown medication problems and adverse drug events, and provided little information on patient mortality. An older meta-analysis of 61 randomized control trials reported there was decreased mortality, lower readmission rates, and improved satisfaction of patients and caregivers54 with the HaH program. Additionally, a meta-analysis of hospital to home integrating a pharmacist into the model has been shown to have a positive impact on medication safety. Ongoing challenges to the program include lack of a regulatory framework, alterations in the electronic health record, and payment and billing mechanisms.55,56


Home-based care programs have been designed to better manage patients who transition from the acute care environment to their home environment and to keep patients out of the hospital if their care can be provided safely in a home environment. The rising cost of healthcare, patient preferences, as well as the known risks associated with hospitalization (e.g., nosocomial infections, delirium, and other adverse events) have led to increasing demand for home-based care programs.57 As more patients prefer to receive care in the comfort of their homes, alternatives for post-acute care continue to be explored; however, it is essential that these alternatives to hospital care be shown to provide high quality and safe care.

Vanessa McElroy, MSN, PHN, ACM-RN, IQCI
Director, Care Transition and Population Health Care Management
UC Davis Health

Ron Billano Ordona, DNP, FNP-BC, GS-C
Health Sciences Assistant Clinical Professor
Betty Irene Moore School of Nursing
UC Davis Health

Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA
Co-Editor-in-Chief, PSNet
Clinical Professor
Betty Irene Moore School of Nursing
UC Davis Health


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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