A Crucial Step to Improve Care in Heart Failure: Integrating Home Health Care into Learning Health System

Dr. Madeline Sterling, Associate Professor of Medicine in the Division of General Internal Medicine, emphasized in a recent viewpoint the importance of integrating home health care into the learning health system (LHS) to strengthen care delivered to patients with heart failure. Though LHS gathers data throughout the entire care process and leverages it to optimize treatments in real time, integration with home health care services remains underdeveloped.

Dr. Madeline Sterling

The viewpoint, which is related to Dr. Sterling’s R01 funded National Heart, Lung, and Blood Institute grant, suggests that while LHS has been widely adopted in hospitals and outpatient networks, one critical sector remains largely excluded: home health. This exclusion is especially concerning for older adults with heart failure who are hospitalized frequently and often use home health care services to ease the transition from hospital-to-home.

Home Health Care, which is provided by Medicare, includes skilled nursing and physical therapy visits and some home health aide hours. Dr. Sterling’s prior study suggests that 1 out of 3 Medicare beneficiaries hospitalized for heart failure are discharged home with home health care services. These patients are at high risk for readmission, but this can be curbed when home health care is delivered optimally. This includes home care nurse visits soon after the patient arrives home and timely outpatient medical visits with clinicians.

Hospitals and outpatient networks have implemented LHS using electronic health records (EHRs) to store, analyze and share patient data. However, data from the home and the home care agencies serving patients, rarely makes it back to the hospital and ambulatory practices in which they also receive care.

To fully realize the potential of LHS, Dr. Sterling states, home health care must be better integrated. This would allow data from home care visits to be used in real time for better patient care and to prevent complications. For example, if the LHS included care provided at home, then home care nurses would be able to receive the hospital discharge summary in real-time and manage symptoms and reconcile medications faster. However, barriers such as poor care coordination, at times, between hospitals, home health agencies and outpatient providers, exist.

Looking forward, Dr. Sterling and colleagues suggest that while some barriers require big systemic changes to overcome, others can occur now. For example, increased awareness from physicians is needed so they can refer patients to home health and actively encourage its use. Additionally, hospitals and home health agencies can work to improve information sharing, particularly after a patient is discharged, according to Dr. Sterling.

To better integrate home health, implementation science is likely to play a critical role. It can guide providers on adopting effective strategies, such as enhancing communication and data sharing, which may result in better health care delivery and improved patient outcomes.