Minnesota uses home health services following a hospital discharge much less than the nation – 54% compared to 71%, with our rural communities having lower acceptance than urban areas. And, those patients that should have received home health, but did not, had a 10% higher 30-day re-hospitalization rate than those that did receive home health services. In early 2018, Stratis Health began leading a Centers for Medicare & Medicaid-funded statewide collaborative of home health agencies, hospitals, nursing homes, and others to address these gaps. Several tools for increasing the acceptance and use of home health services following a hospitalization have been developed and pilot-tested, and they are now ready for broad dissemination.
Janelle leads the Stratis Health Coordination of Care and Rural Palliative Care initiatives. She is currently working with ten community-based groups across Minnesota to improve care coordination by bringing community partners together to address their local issues. Janelle has extensive experience at Stratis Health leading quality improvement programs related to hospital, home health care, patient safety, and palliative care. She holds a Masters of Nursing from Bethel University and a Bachelors of Science in Nursing from the University of Iowa.
Kristy has worked in home care and hospice for 13 years, holding positions that range from field Physical Therapy, to rehab coordinator, and now serving as the director for CentraCare Health’s agency. Kristy also has clinical experience in the outpatient and nursing home settings. She has presented numerous times at various local conferences.