When Dependable Home Health Services in Nogales, AZ, began an initiative to reduce its readmission rate, 23% of patients served by the home health agency were readmitted to the hospital within 30 days. Within a year, the readmission rate was reduced to 19%.

Dependable Home Health Services currently serves a low-income, majority-Hispanic population with an average age of 76. About 85% of the patients are dual-eligible Medicare and Medicaid beneficiaries. The rest are covered by Medicaid. About half of the patients have been discharged from a hospital and about 15% from another post-acute facility, such as a rehabilitation facility or skilled nursing facility, reports Jill Lanning, RN, BSN, chief nursing officer.

Most of the patients are discharged to home from the hospital because there are no post-acute facilities in their county and they don’t want to be far from home, reports Arlene Madsen, RN, BSN, quality consultant. Fully 95% are discharged with a change in the medical regime. There is a critical access hospital in Nogales, but the majority of the patients are transferred to hospitals in Tucson for specialized treatment, Madsen says.

The agency staff faces a variety of roadblocks to ensuring that patients follow their treatment plans and avoid unnecessary readmissions, Lanning says.

Many patients do not speak English and although they speak Spanish, they cannot read Spanish, she adds. Often, they can’t afford the copay for their medicine or the type of foods they need to get well. Many have low health literacy and don’t understand their medication regimen.

In January 2016, the home care agency began meeting with representatives of the federally qualified health center in Nogales to work together on better meeting patient needs. Other agencies and providers joined throughout the year and the monthly meeting now includes the medical director from the local hospital, case managers and social workers from the hospital, the medical director, pharmacist, and a care coordinator from the health center, representatives from the local fire department, two health plans, adult protective services, and two additional clinics.

“We want to build relationships and collaborate on ways to work with patients to keep them from going to the emergency department for situations that could be solved at the primary care provider level,” Lanning says.

For instance, in the past, when the home health nurses or patients called the health center because patients experienced high blood pressure, high blood sugar, or other issues, they often were referred to the ED because the clinic didn’t have any slots for appointments. As a result of the meetings, the health centers leave a few appointments open every day so patients who call in with non-emergent problems can get in to see a physician instead of going to the ED.

Representatives of the community organizations worked together to produce a standardized patient information booklet that patients take with them on provider visits, Lanning says. Each time they see a patient, providers enter information such as medication, chronic conditions, physician notes, vital signs, and other information. “This ensures that everyone has the same information about the patient and that we all know what the other providers are doing,” she says.

The next goal is to sync providers’ electronic health records so the home health agency, the clinic, and the hospital all have access to patient information, she says.

The majority of nurses and nurses’ aides who work for Dependable are bilingual and live in the community they serve. “We get a jump on building trust when our employees speak the same language as the patients and understand their culture and their community,” Lanning says.

Medication issues are the biggest problems, Lanning says. “Many times, patients are discharged with prescriptions that they don’t take correctly. It may be because of finances or because they don’t understand their instructions,” she says. Often, patients take their prescriptions across the border to a Mexican pharmacy that provides the medicines at a lower price than they would pay in the U.S.

However, in Mexico, pharmacies are not required to have a licensed pharmacist on staff and manufacturers of medication don’t have to follow U.S. FDA regulations, she says.

“We try to educate our patients on the importance of getting their prescriptions filled by a pharmacy on the U.S. side, but we tell them that if they do go to Mexico to get their medication, we want to check it over before they take it,” Madsen says.

The home health provider also works with pharmacists from the health centers to help with medication reconciliation.

The Rio Rico Fire Department staff was already making health check visits to people who frequently call 911 for health issues, and agreed to also see vulnerable patients referred by the Dependable Home Health nurses. The fire department staff have been trained to perform a medication review as well as monitor blood pressure and other vital signs.

“It’s all a part of our community collaboration to see that patients get the services they need to stay healthy and out of the hospital,” Lanning says.

Many of the patients served by the agency are low income, have little education, and speak only Spanish. The nurses use educational materials written on the fourth- or fifth-grade level, but some patients can’t read. In that case, the nurses educate the patients orally and use the teach-back method to make sure they understand, Madsen says.

“It takes an individualized approach to getting patients engaged in disease management. Sometimes, we educate the patient; other times, it’s a family member,” Madsen say.

Many patients eat a diet that is low in protein because they can’t afford meat, Lanning says. This poses a problem for patients with wounds since increasing protein in the diet helps wounds heal, she adds. “We contact the patients’ family members who live in another area and ask them to send protein powder or money for protein powder so they can supplement their diet,” she says.