Improving Continuity of Care Through Standardized Care Transition Protocols in Medicare Certified Home Health Agencies
Abstract
Three intervention models, the Care Transitions Intervention, the Transitional Care Model, and the Re-Engineered Discharge process, anchor most of what is known about reducing harm at hospital-to-home transitions, yet none was designed for the specific administrative architecture of a Medicare-certified home health agency operating under referral intake, face-to-face order authentication, and Outcome and Assessment Information Set assessment requirements. This paper asks what a standardized, home health-specific care transition protocol suite would need to contain to translate the mechanisms these models identify, patient activation, comprehensive case management, and structured discharge process, into procedures an intake coordinator, a certifying clinician, and a field nurse can actually execute inside existing Conditions of Participation workflow. Building directly on a companion governance framework (Ogundipe and Ominde, 2024), the paper synthesizes the transitional-care, home health nursing, medication reconciliation, and readmission literatures critically around a design question rather than an evaluation question, and proposes six protocol modules, structured intake, risk-stratified OASIS-anchored assessment, face-to-face order authentication, structured medication reconciliation, SBAR-based interprofessional handoff, and a 48-hour first-visit and escalation protocol, each specified with its source model influence, its fidelity criteria, and the specific administrative failure mode it targets. The paper states eight fidelity-linked hypotheses and a stepped implementation design appropriate to testing a protocol suite across multiple agency sites without withholding a plausibly beneficial practice from any site indefinitely. No protocol in this suite has yet been implemented or evaluated; the contribution is a design specification, together with the fidelity measurement and evaluation architecture a rigorous test would require, built to make explicit which component of "standardization" is doing the work when, and if, continuity of home health care improves.
References
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