The authors of a new study suggest that hospitals are not providing patients with enough education about home health services, leading to unrealistic expectations after they are discharged home.

  • One issue is that primary care physicians and home health agencies often lack communication from hospitals about discharge plans.
  • Another issue is that home health nurses often believe they have difficulty reaching a hospital clinician when questions arise about a patient.
  • Discharged patients and their caregivers often need and believe they will receive more support services from the home health agency than what can be provided.

Patients discharged home often lack necessary education about home healthcare services, leading to unrealistic expectations, new research shows.1

Home health agencies (HHAs) also report that they do not receive all of the information they need from hospitals to provide optimal patient care.

“It’s variable how many hospitals might send their discharge summary and other information to primary care physicians [PCPs] and home health agencies,” says Christine D. Jones, MD, MS, assistant professor at the University of Colorado School of Medicine in Denver.

“Both primary care physicians and home health agencies frequently are left out of the loop,” Jones adds.

“We were interested in finding out how widespread this problem was,” she says. “We found that 60% had insufficient information to guide patient management, and 44% encountered problems related to not having enough information.”

Jones and co-investigators studied hospital-to-home communication because of problems they observed. “We had done some qualitative work with home health nurses in the Denver area, and it seemed like a theme that kept coming up was they had a lot of challenges in getting hold of the hospital clinician,” she explains.

“Previously, I had done a study talking with primary care physicians, and no one was clear how to manage home health orders after a patient was discharged,” Jones says. “The hospitalist thought that once the patient was discharged, the information was transferred to the PCP, and so we realized there was a big gap.”

The researchers also notes that caregivers sometimes have unclear expectations for home healthcare because they actually need more support after the hospital discharge. This suggests that hospital case managers and case management teams could play an active role in assessing and providing additional support.1

From the perspective of HHAs, communication could improve if a single point of contact, such as a case manager, could help connect HHA staff with physicians, Jones says.

HHAs also can send a liaison to the hospital before discharge to meet with the patient, physician, and hospital case manager, she adds.

“That is a solution that home health agencies have suggested is very helpful,” Jones says.

The communication gap can be fixed in a variety of ways, including these strategies:

• Use electronic health records to improve communication. In the study, the researchers found that having access to electronic health records (EHRs) helped improve communication between hospitals and home health agencies, Jones says.

“In analyses, we found that those who had access to EHRs were much less likely to have these problems related to lack of information,” she says. “They were much more likely to have the information they needed about medication and more than twice as likely to have sufficient information about medications.”

A communication gap still existed, but EHR access helped address some of that gap, Jones adds.

For instance, even when the HHA had EHR access, the agency still had difficulty reaching a clinician after discharge.

“That’s something we need to work on independently of electronic exchanges,” Jones says. “Let’s make sure we know who the person is that the home health agency can reach, and let’s provide them with direct contact.”

• Improve interoperability between electronic health systems. “Interoperability between the hospital’s electronic health record and the home health space is not optimal,” Jones says. “The more we can work on having health information exchanges and interoperability across the electronic health records, the better.”

Not all hospitals participate in health information exchanges, and this also poses an obstacle.

“The more we can fill in some of these gaps, getting everyone to participate in an exchange or getting systems to be interoperable, or maybe both, it would improve access to information,” Jones says.

• Assess hospital communication processes. “It’s a good idea to do a quick environmental assessment of how your hospital is doing and to see if there is a communication problem,” Jones suggests. “If you find there are communication insufficiencies, talk with key partners, such as home health agencies, to get an idea of what it’s like for them and what they need.”

For example, a home health agency might say they need a single point of contact to call when they have a question and need a speedy answer. Or the agency might find that some information is missing, and they need someone to call to help fill in the blanks, Jones says.

“I’ve heard that issue a lot,” she says. “They want one phone number.”

Hospital case managers will benefit from building a relationship with home health liaisons, reaching the same person or office on a regular basis, she adds.

• Prepare patients for home health services. A surprising finding was that respondents did not feel like their patients were prepared to receive home health services, and no one had explained these services to them, Jones says.

“I asked if they knew what skilled home health was, and the answer was that patients expected home health professionals to spend extra hours providing caregiving, transportation, and cleaning services,” she explains. “People described how they would go into the home, and the patient or caregiver was upset because they weren’t getting the help they thought they were going to get, and the home health professional had to rebuild that relationship.”

Hospital case managers should educate patients about what to expect when they head home to receive home health services.

“Make sure patients aren’t disappointed,” Jones says. “This is something we can do better from a hospital perspective — have better education about home health services and give people something easy to read, easily understandable information.”

If patients and caregivers suggest they need unskilled home care services, then a case manager could give them information about private duty services.

“This was the biggest thing people were talking about,” Jones says.


  1. Jones CD, Jones J, Bowles KH, et al. Patient, caregiver, and clinician perspectives on expectations for home healthcare after discharge: A qualitative case study. J Hosp Med 2019;14:90-95.