When Home Health Services Never Arrived

The Challenge

A 72-year old Medicare patient with a past medical history of COPD, hypertension and dementia was discharged home with home health, with the expectation that the assigned home health agency would visit the patient immediately upon discharge. 

At the 24-hour check-in, the Care Continuity Navigator learned the patient had not yet been contacted by the agency. The Navigator reconfirmed in the patient’s chart that the home health order was placed and the home health agency assigned.

What We Did

The Navigator contacted the patient’s assigned home health agency directly and discovered that the agency was unaware of the patient’s recent discharge. They had not received the necessary Resumption of Care (ROC) order required to restart services.

After confirming the gap, the agency requested updated ROC orders in order to initiate care. Following the established escalation protocol, the Navigator reached out to the social worker at the discharging hospital to obtain the new orders. Once secured, the orders were promptly forwarded to the home health agency, enabling services to begin without further delay.

The Impact

• Prevented a gap in care by ensuring the home health agency received the appropriate orders.
• Enabled earlier clinical oversight, allowing home health clinicians to monitor symptoms and support recovery.
• Reduced the patient’s risk of complications or deterioration that could lead to an emergency visit or readmission.
• Identified a systemic issue with home health orders for one specific agency, preventing this barrier from happening again for future Inpatient discharges

Why It Matters

Timely home health services are critical to a patient’s recovery after discharge. When orders are missing, delayed, or never received by the agency, patients can be left without the clinical support they need to manage medications, monitor symptoms, or continue treatment at home. Research shows that home health care delays of more than two days after hospital discharge increase the risk of a 30-day readmission or emergency department visit by 12%. By identifying and resolving these gaps quickly, Care Continuity helps ensure home health services begin as intended—supporting safer recoveries and preventing avoidable returns to the hospital.

• Patient discharged to home after inpatient stay
• Care plan included Home Health visit at 24 hours
• Home Health service never showed up
• Navigator call at 48 hours revealed the barrier 
• Readmission risk escalated and resolved immediately