“…Hospitalization exposes already vulnerable older adults to the risk of medical errors (Institute of Medicine [IOM], 1999, 2003), and is associated with reduced functional status (Cornette et al, 2006; Graf, 2006), reduced quality of life (Naylor, Stephens, Bowles & Bixby, 2005), and a shorter time to death (Lum, Studenski, Degenholtz, & Hardy, 2012; Mandawat, Mandawat, Mandawat, & Tinetti, 2012). Often in partnership with acute care organizations and primary care physicians, Medicare-certified home health providers have been seeking ways to reduce 30-day readmissions among Medicare-reimbursed home health patients.…”