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Home Care – Preventing Acute Care Hospitalization - BVNAH

Reducing preventable rehospitalizations is a national goal. The Centers for Medicare and Medicaid Services (CMS) is leading the focus on avoidable hospitalizations as part of healthcare reform, and will adopt reimbursement tactics to support this goal which will become effective in 2013.  Homecare has been charged with reducing unnecessary hospitalizations, and the BVNAH has embraced our responsibility to contribute to this outcome.  We have partnered with Baystate Health and the State Action to Avoid Rehospitalization (STAAR) Project, where patients at-risk for hospitalization are identified early, and a standardized discharge plan and prescribed follow-up is enacted.  When Homecare is needed, the standardized follow-up is reinforced in the home in addition to the routine care normally provided to manage safety through medication management, various risk assessments and nutrition, and optimization of outcomes related to functional and cognitive ability.



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Baystate Visiting Nurse Association and Hospice

The Homecare team has had great success in the utilization of Telemedicine for patient assessment and education. 

  • Telehealth does not replace traditional face-to-face visits but augments them and allows patients to closely monitor (with standard parameters) on a daily basis their heart rate, blood pressure, oxygen saturation, and weight from the comfort of their own home. 
  • Those measurements are recorded and faxed daily to patient care providers.
  • The providers work with physicians to determine the early appropriate intervention, which is key to keeping patients with heart failure out of the hospital.  


The Homecare team has had success with the utilization of Integrated Chronic Care management which focuses on patient's and caregiver's engagement for self-management.


For more information on Quality at Baystate Health

For more information on Baystate Visiting Nurse Association and Hospice

For more information on the STAAR Initiative