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Consider Home Care


Health Care s Cost Effective Solution CONSIDER HOME CARE Our readmission rates remain high, especially in Eastern Massachusetts * Although regional differences for ... – PowerPoint PPT presentation

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Title: Consider Home Care

Health Cares Cost Effective Solution
  • Consider Home Care

Section 1 An Overview Why Home Care? And Why
Why Home Care? Why Now?
  • As part of a plan of skilled and supportive care,
    home health agencies have in place an
    infrastructure to
  • Reconcile and assure adherence to medications
  • Initiate personalized teaching and health
    coaching for chronic illness, self-management
    support strategies
  • Conduct in-home safety evaluations, depression
    screening, and falls risk assessment and
  • Coordinate other non medical community resources

Fact Innovative, low cost, evidenced-based
practices are being used in home health care
today to achieve the goals for safe, effective,
patient-centered care that are at the heart of
new global payment, medical home or accountable
care contracts.  
Why Home Care?
  • High quality home health agencies have capacity
  • Provide intense clinical interventions at home
    (e.g., providing a patient after only two
    hospital days with a course of 14 days home IV
  • To assist in managing risk (e.g., this same
    patient has much lower risk of nosocomial IV line
    infection) and
  • Because of their intense focus on patient and
    family goals, to improve patient satisfaction

Together We Have a Lot of Work To Do
Source Medicare Hospital Quality Chart Book,
And We Can Do Better..
No... but, of 2,836 hospitals included in the
measure, 2.7 performed better than the national
rate of 5.7, and 1.8 performed worse than the
national rate. Four divisions (New England,
Middle Atlantic, East North Central, and East
South Central) had more hospitals that performed
worse than the national rate than hospitals that
performed better.
Hospital Discharge Disposition - MA
Data January 2011- December, 2011, Source
Clinically and Cost Effective Placement
Example Comparing average payments across first
post acute settings, it is clear that home
health is the most cost-effective. For example,
the average first setting Medicare payments for
MS-DRG 470 (major joint replacement) are
  • Innovative approaches to the use of post-acute
    care could be key to improving patient care at a
    lower cost
  • A recent study showed that patients with similar
    clinical and demographic characteristics are
    receiving post-acute care in various settings

Home Health 3,267
Skilled Nursing Facilities 8,981
IRF 13,073
LTCH 27,399
Section 2Improving Care Transitions/Reducing
. Seamless Transitions
A referral to home care following a hospital
discharge or an emergency room visit gives
patients the support and services they need to
stay safe at home.
  • At the time of the first home visit (usually
    within 24 hours), your patients
  • Home environment is assessed for hazards that
    might increase risk of a fall or other injury
  • Medications are reconciled and teaching is
    initiated to support compliance and
  • Need for referrals for therapy, home health
    aides, /or social work are evaluated.

Example Complications of a late Friday
discharge can be avoided with a homecare nurse or
therapist visit the next day to ensure ordered
medications are in the home, discharge
instructions are in place and being followed,
appointments are set as needed, direct care
provided as ordered.
Preventing Re-hospitalization
  • Massachusetts Medicare patients who are referred
    for post acute home health services will receive
    an average of 20 visits within 60 days of leaving
    the hospital
  • Patients leaving the hospital can also be
    referred for care transition support, outside of
    the Medicare benefit, on a fee for service basis
    for a one time home or medication evaluation,
    short term coaching or telephonic support, to
    support compliance with discharge orders, or
    setting up a private pay care plan.

Example A patient who has fallen at home once
is more likely to do so again. Yet patients
suffering from balance dysfunction can find it
difficult to travel to outpatient rehabilitation
programs because they are not mobile enough or
cannot find a caregiver to transport them. A
home-based falls risk assessment can evaluate and
address changes to a cluttered living area, risks
from medication side effects, or elevated blood
pressure, as well as issues with strength or
flexibility. The plan may involve home
modification advice and balance therapy.
The Home Care Teamwork Approach
  • In a post acute episode of care, home health is
    required to coordinatewith the patients Primary
    Care Physician.
  • The home care nurse or therapy team will
  • Contact the physician to establish
    patient-specific clinical parameters for
    notifying him/her of changes in vital signs or
    other clinical findings
  • Work with the patient and family on the
    importance of patient follow-up with the
    physician within 5 days of discharge and assure
    that appointments are set up
  • Provide patient/family instruction on early
    indicators of symptom exacerbation and whom to
    contact, what to do, and under what
    circumstances and
  • Collaborate on highest risk patients, including
    those who may not be able to access an MD office
    either permanently or temporarily.

Focus on Patient Education
  • Example
  • Patients go to the ED when they cant reach a
    professional caregiver.
  • Home care teaches the patient/family to contact
    a member of the home care team first, for
    concerns about increasing symptoms or changes in
    their health status.

Section 3Managing Chronic Illness
Managing Chronic Illness
  • Studies show that as the number of chronic
    conditions increases so do hospitalizations.
    Beneficiaries with multiple chronic Illnesses
    account for the MAJORITY of all hospital
  • Only 4 of beneficiaries with 0 or 1 chronic
    condition were hospitalized and less than 1 were
    hospitalized 3 or more times during the year
  • Almost two-thirds of beneficiaries with 6 or
    more chronic conditions were hospitalized and 16
    had 3 or more hospitalizations during the year.

A Picture Tells the Story
Home Care Knows Chronic Illness Management
Home health care clinical teams, under directives
from physicians, are able to help patients manage
chronic disease effectively at home, resulting in
significant reductions in unnecessary
  • The home care based chronic care model includes
  • High touch hands on care and teaching often
    from teams with specialty training and managing
    and teaching clients with diabetes, congestive
    heart failure and chronic obstructive pulmonary
  • Technology, in the form of remote monitoring or
    Telehealth that transmit vital signs daily
    providing for early identification of changes in
    condition and more timely interventions leading
    to reduced hospitalizations and
  • Self management support around management of a
    chronic illness.

Home Care Knows Chronic Illness Management
  • Example
  • For CHF patients, an HHA can provide critical
    services to prevent hospitalizations or ER
    visits, including
  • Conducting one on one education about the CHF
    Zones of Management and when and whom to call
    for help
  • Teaching how to take and manage medications and
    diet, especially sodium intake
  • Teaching use of oxygen in the home
  • Conducting in home or remote observation of
    weight, breathing, presence of edema or pulmonary

Fact Most physician groups are not equipped to
effectively manage chronically ill patients. Home
care can be the extension of the physician
practice, providing the varied disciplines,
patient education and in-home visits.
Section 4 Managing Advanced Illness
What is Palliative Care?
  • Specialized or generalist medical care for people
    with serious illness and their families
  • Focused on improving quality of life as defined
    by patients and families
  • Provided by an interdisciplinary team that works
    with patients, families, and other healthcare
    professionals to provide an added layer of
    support and
  • Appropriate at any age, for any diagnosis, at any
    stage in a serious illness, and provided together
    with curative and life-prolonging treatments.
  • Definition from public opinion survey conducted
    by ACS CAN and CAPC http//
  • Diane Meier, Center to Advance Palliative Care

Palliative Care Teams Address Three Domains
  • Physical, emotional, and spiritual distress
  • Patient-family-professional communication about
    achievable goals for care and the decision-making
    that follows and
  • Coordinated, communicated, continuity of care and
    support for social and practical needs of both
    patients and families across settings.

Dont ask whats the matter with me. Ask what
matters to me.
Palliative Care at Home for the Chronically Ill
Improves Quality, Markedly Reduces Cost Service
Use Among Heart Failure, Chronic Obstructive
Pulmonary Disease, or Cancer Patients While
Enrolled in a Home Palliative Care Intervention
or Receiving Usual Home Care, 19992000
Source KP Study Brumley, R.D. et al. JAGS 2007
Diane Meir, Center to Advance Palliative Care
Hospice/Palliative Care Screening
  • Advanced life-limiting illnesses?
  • Severe dementia (unable to bathe, urinary
    incontinence, etc.)
  • Severe CNS disease (e.g., recent acute stroke,
    progressive neurological decline)
  • Cancer (with or without metastasis)
  • Congestive heart failure (with marked activity
  • Chronic obstructive pulmonary disease (requiring
    home O2)
  • AIDS (CD4lt200 or AIDS defining illness,
    progressive decline)
  • Other advanced disease (pulmonary hypertension,
    CAD, other)
  • 2) Has the patient had progressive losses of
    Activities of Daily Living and/or a severe
    decline in functional status? Yes / No3)
    Does the patient demonstrate any of the following
    unmet needs?
  • Guidance with pain and/or non-pain symptom
  • Advance Care Planning/Advance Directives issues
    related to continuing health care needs
  • Guidance with healthcare decision-making
  • Bereavement Issues negatively impacting health
  • Frequent hospitalization for advanced illness
  • If Yes to Questions 1 and 2 Patient/family
    would benefit from Hospice Consult.
  • If Yes to Questions 2 and 3 Patient/family
    would benefit from Palliative Care Consult.

Home Care Delivers Satisfied Patients
Patient Satisfaction Survey
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