The PPH Wake-Up Call: What Every Agency Needs to Do Now

Written by Michelle Horner, Clinical Consulting & Education Manager, McBee

Potentially Preventable Hospitalizations (PPH) now account for 26% of the Total Performance Score in Home Health Value-Based Purchasing (HHVBP), yet many organizations still underestimate just how much opportunity (and risk) lies inside this single measure. PPH isn’t just a quality metric. It’s a reflection of how well an organization identifies risk, collaborates as a team and delivers the care it plans to deliver.

And that’s the heart of the issue:
Most organizations are not struggling because they don’t know what to do, but because they aren’t consistently doing it.

In our recent webinar, The PPH Playbook: Strategies to Reduce Hospitalizations in HHVBP, we break down the clinical, operational and interdisciplinary teamwork strategies that help organizations prevent avoidable hospitalizations. Below are some core takeaways that highlight why PPH deserves urgent attention, and why every organization should revisit how its team works together.

1.  Risk Identification Isn’t About Checkboxes: It’s About Conversations

If a team cannot accurately identify risk, it cannot meaningfully prevent hospitalization. Yet, one of the most common gaps we see is clinicians rushing through M1033 or relying on yes/no questions instead of true clinical inquiry.

M1033 isn’t simply a regulatory requirement, it’s a roadmap to what will put your patient in the hospital.

The problem? Too often clinicians:

• Don’t ask open-ended questions
• Don’t explore the “why” behind the risk
• Don’t dig into symptoms or patterns
• Don’t connect risks to an actionable plan

When risk capture is shallow, your care plan becomes generic rather than personalized, and generic care plans rarely prevent hospitalizations.

2.  No More Silos: PPH Prevention Takes an Entire Team

Hospitalizations frequently happen not because risks are unknown, but because the team isn’t working together to address them.

Consider medications, a major driver of PPH:

• Nursing can teach, reconcile and organize medications.
• OT ensures patients can actually open bottles, sort pills and manage fine motor tasks.
• PT ensures the patient can safely access wherever meds are stored.
• Speech therapy evaluates swallowing safety and cognition.
• MSW addresses affordability, insurance barriers and transportation.

When one discipline owns the whole issue, cracks form. But when every discipline knows their role in preventing a hospitalization, patient safety becomes a shared mission.

This is true for falls, chronic conditions, emotional distress, cognitive decline, nutrition, isolation—everything.

3.  SDoH: The Hidden Risks Too Many Agencies Overlook

Social determinants of health (SDoH) have just as much impact on hospitalization risk as clinical diagnoses, sometimes more. Unfortunately, MSWs are often underutilized, or agencies don’t have enough MSW coverage to meaningfully address risk.

Every clinician should know:

• Where to access food assistance
• How to refer to Meals on Wheels
• What utilities, transportation and financial resources exist locally
• How to recognize when a patient can’t afford medications or appointments

The research is clear: programs like Meals on Wheels reduce ED utilization, rehospitalization and loneliness while improving safety. If an agency ignores SDoH, it’s ignoring preventable hospitalizations.

4.  Comorbidities Cannot Be an Afterthought

A major trend seen in rehospitalization reviews is this:
Patients often return to the hospital for conditions unrelated to the primary reason they are on service.

If a patient is being seen for a knee replacement but also has diabetes, COPD or CHF, those chronic conditions don’t go on hold for 60 days. They still require monitoring, teaching and symptom awareness.

The entire team, not just nursing, must understand triggers for when to involve other disciplines to manage comorbidity-related risks.

5.  Implementation Is Everything: A Plan of Care Doesn’t Matter If It Isn’t Followed

Many organizations can identify risk. Many can write a beautiful plan of care.
But far fewer consistently implement what’s written.

That’s where hospitalization risk skyrockets.

Preventing PPH requires:

• Intentional interdisciplinary case conferencing
• Clear team roles
• Frequent follow-up in the first 7–10 days
• Timely referrals
• Regular review of progress
• Accountability to the care plan

Every discipline should know what the others are working on and how they can reinforce those interventions.

If You’re Serious About Reducing PPH, Start Here

Three areas should be the foundation of every organization’s hospitalization prevention strategy:

• M1033: Ask deeper questions. Capture the true picture. Build the plan around the risks identified.
• Comorbidities: Monitor them consistently, especially when they’re not the primary home health diagnosis.
• SDoH: Addressing food insecurity, transportation, income strain, loneliness and safety isn’t “extra”, it’s core to preventing hospitalization.

And when those risk factors are identified, immediate action should follow.

Adding simple, evidence-based strategies like frontloading and 7 touches in 7 days improves trust, catches early deterioration and stabilizes patients during the most vulnerable week of service.

Want to Learn More? Watch the Webinar 

Our full webinar dives deeper into:

• How to teach clinicians to ask the right questions
• Keys to designing personalized care plans
• Discipline-specific interventions for common hospitalization risks
• Strategies to build true interdisciplinary collaboration
• Episode Management workflows that help prevent decline

If your organization wants to improve PPH performance, strengthen HHVBP outcomes or build clinician confidence in risk assessment and collaboration, this webinar is a great place to start.