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Improving Integrated Care

CommonSpirit Health at Home created a collaborative solution involving care at home experts integrated into CommonSpirit Health’s Care Coordination department.

One of the clear silver linings of the pandemic is that consumers increasingly prefer the comfort, convenience and safety of receiving care at home. On average, home care utilization is up 16% from pre-pandemic levels, fueling the development of new care delivery models, solutions and processes.*

Ensuring a successful transition for patients discharged from an acute care hospital to the home environment can be challenging. Patients are often unaware of the care they require post-discharge. The ‘Health at Home Navigator” (HHN) educates the patient and family on what is afforded to them with Home Health benefits and expectations of the capabilities of the providers from CommonSpirit Health at Home. It allows patients and their family members the time and opportunity to ask questions and work through plans for discharge when considering, “why not home?”

Moving the care destination and selection-process discussion to the day of admission supported by a HHN embedded at the hospital drives stronger alignment within our own ecosystem, that will improve care across the continuum. 

The HHN serves as one contacting and communication link, with ease of access for integrated services across an expansive geography. This specialized expert helps design a smooth transition home for patients, beginning at admission, and in alignment with care management. 

In addition, this specialized role focuses on early transitions that require care in the home and coordinates efforts to support our at-risk population, resulting in improved outcomes.  

While in the early stages of implementation, we are seeing: 

Improved care continuity and patient engagement 

  • Decreased acute care LOS 
  • Increased utilization of home care 
  • Improved system integrity of owned assets 

As the program grows and utilization increases we expect to see enhanced integrated clinical workflow between providers, care managers and home-based services through a centralized process upon admission. 

Our next phase of implementation is to expand into CommonSpirit Health markets with a home health presence leading to the future state of a ministry-wide HHN model across the entire platform. 

As the HHN enhances and speeds the process to drive care destinations, the collective commitment will transform patient engagement, increase utilization of cost-effective home health care services and improve capacity within our hospital partners. 


1. Holly, Robert. “Home Health Patient Volume Hits 116% of Pre-Pandemic Baselines.” Home Health Care News, 6 May 2021,

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