Patients Who Refuse Home Health Experience 25% Higher Mortality

Physician Bulletins: Below, you will find a sample of the community-based healthcare utilization bulletins that we routinely mail to referring doctors and other healthcare professionals.

A study published earlier this year found that patients who refuse home health cost $15,233 more in one year compared to the patients who accepted their home health referral.¹ Patients who refuse home health tend to be younger, better educated, and healthier than those who accept, but their one-year mortality rate climbs 25% higher than their sicker counterparts, and they prove twice as likely to have hospital readmissions within 30 days.^1,2 Patients who accepted home health also reported higher quality of life.² In general, when patients are homebound and have a skilled need, electing self-care may compromise medical outcomes and increase one-year spending compared to receiving home health. How much of a problem is this? In one study, 28% of patients at academic medical centers refused their home health referrals.²

Research directly addressing the causes of this problem is scarce, but the literature does allude to possible causes. This literature was analyzed in an expert roundtable, and the results were published by the United Hospital Fund in 2017.³ Notes on their conclusions follow:

Some research suggests that families conflate non-medical home care with Medicare-certified home health, and don’t see a need for insurance to pay for cleaning and cooking. When introducing the subject of a home health referral, it may be helpful to say, “I’m going to send a registered nurse and physical therapist to your home,” rather than saying “We’ll send home health.”

Similarly, families may be assuming they can perform skilled medical care at home without further training or follow-up, thereby sav-ing money for payors or themselves. It may also be helpful to summarize skilled activities with statements such as, “They’ll make sure your recovery is going according to plan,” “I want the nurse to check your wound healing,” or “I want the physical therapist to see when you are ready to progress your exercise difficulty.” For patients with traditional Medicare, you can also say that Medicare pays 100% of home health charges. Regardless of payor, doctors and discharge planners can also explain, “Research shows that for peo-ple in your situation, on average, a few follow-up visits at home saves thousands of dollars over the next 12 months.”

Finally, geriatric patients may perceive home health as an affront to their independence or a disparagement to their capability or work ethic. When proposing home health, it may be helpful to avoid paternalistic terms such as “care,” “help,” “watch after,” and “look out for.” Proposing a specific medical need for home health may avoid conflict with a patient’s sense of independence. This may include phrases such as “assess the effects of your new medications,” “assess the effects of this exercise plan,” “work on emergency planning in case your condition takes a turn for the worse,” “to draw blood for our lab work,” etc.

Regardless of the individual rationale for refusing a home health referral, we now know that when doctors and discharge planners see a need for home health, it proves counterproductive for patients to refuse it. This is true in terms of cost, quality of life, and mor-tality. It can definitely be worthwhile to explore a patient’s personal reasons for refusing home health and to emphasize the utility of those home visits.