Each year, close to 2 million patients over 65 are readmitted to the hospital within 30 days of discharge. While these readmissions result from a variety of issues, a lack of care coordination from hospital to home seems to be the most common cause.

“Most patients want to return home after hospitalization, but they are often physically compromised, their caregivers are unprepared, and the start of home services is delayed,” said Rebecca Trotta, PhD, RN, director of Nursing Research and Science at the Hospital of the University of Pennsylvania (HUP). All of these factors can lead to a longer hospital stay, a riskier recovery at home, and potentially unnecessary readmission.

Now, a new initiative at HUP called SOAR (supporting older adults at risk) is working to reverse that trend, getting patients home sooner and keeping them there longer. Based on a program that originated at Sheffield Teaching Hospitals in the United Kingdom, SOAR “flips” the discharge process. Before the patient leaves the hospital, the program coordinates multiple home care resources that will assess patients’ ongoing support needs once they’re home. This includes a visit by a home care nurse soon after a patient arrives home—rather than waiting, on average, 2 to 3 days—and confirming medications and treatment plans by the day after discharge. “One day post discharge is the time when patients and their caregivers are most vulnerable. They are a bit in limbo until their home care begins or they see their primary care provider,” Trotta said.

The success of HUP’s SOAR’s program relies heavily on close collaboration with Penn Care at Home (PCAH). As Trotta explained, while HUP’s geriatric nurse consultants (GNC) can help staff meet the specific needs of inpatients 70 and older, after discharge, “nurses from Penn Care at Home could ensure that these needs would be met at home.”

SOAR represents one of many successful efforts throughout Penn Medicine to reduce admissions through a carefully orchestrated process which includes programs for patients with conditions that place them at high-risk for readmission including cancer, heart disease, gastrointestinal conditions, and sepsis. Indeed, just 1 year after signing a new contract with Independence Blue Cross that brought about new innovations specifically aimed at lowering 30-day readmissions, the health system has cut readmissions among patients insured by IBC by more than 25%—the largest readmission reduction in our organization’s history! Read more here.

According to GNC Colleen Regan, BA, BSN, planning for a possible SOAR discharge starts when the patient is first admitted to the unit, with a comprehensive geriatric assessment. The GNC then stays in constant contact with the inpatient care team—which includes the nurse, provider social worker, and therapists—via Curator, a secure text messaging system. “I’m always reminding the team that this patient might be a good SOAR candidate.”

For a patient to be considered for the SOAR program, the care team must agree that the patient can safely be discharged to home, and the patient must want to return home. Once that’s established, the countdown to discharge—by 10:00 a.m.—begins.

On the morning of discharge, a hand-off phone call between the inpatient care team and Penn Care at Home staff provides essential information for a smooth transition to home, such as changes to the patient’s medication regimen, functional needs, caregiving needs, and plans for follow-up care in the community—“everything that will keep the patient safe at home,” Regan said. In addition to the initial visit by a home-care nurse, a physical therapist, occupational therapist, and social worker come to the home within days of discharge.

“Having the patient seen soon after discharge by an interdisciplinary team is critical. It’s hard to fully appreciate patients’ functional needs until they are assessed in their home environment,” Regan added. “Without early therapy, patients are at risk to lose some of their functional ability.”

A unique aspect of SOAR is that a patient’s hospital providers are readily available to talk with the PCAH nurse to address any outstanding concerns related to the inpatient stay, which leads to a better reconciliation of the treatment plan that is to continue at home. The home care nurse also has a direct line to a HUP pharmacist. As part of the SOAR program, patients receive medications at home via My Penn Pharmacy, removing the need for patients and their caregivers to travel to and from a pharmacy—a factor that many have identified as a “major variable.”

Trotta and her team piloted the program on three patient care units at HUP, focusing on patients living in Philadelphia. Phase 1 of the pilot showed that the mechanisms in place are working. On average, patients were seen by the Penn Care at Home nurse within 3 hours of discharge. Medication reconciliation decreased from an average of up to 6 days to just a day and a half. The pilot has now entered Phase 2, where the steering committee will work to determine changes that could make the program more efficient, improve patient outcomes, and keep the program sustainable.

Multiple variables factor into the overall value of the SOAR program. For example, in addition to making the transition to home much safer, by discharging patients earlier, SOAR also increases the availability of patient beds on the patient care units. But the benefit to patient and caregiver still ranks at number one. As one patient in the pilot noted, “There’s something about the magic of being home that helps me recover.”