CONSIDER HOME CARE

Health Care’s Cost Effective Solution

Section 1

An OverviewWhy Home Care? And Why Now?

Why Home Care? Why Now?

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.  

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;

Why Home Care?

High quality home health agencies have capacity to:

Provide intense clinical interventions at home (e.g., providing a patient after only two hospital days with a course of 14 days home IV antibiotic) ;

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 scores.

Together We Have a Lot of Work To Do

Source: Medicare Hospital Quality Chart Book, 2012

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.

And We Can Do Better…..

Hospital Discharge Disposition - MA

Data: January 2011- December, 2011, Source: Masspro

Clinically and Cost Effective Placement

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

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:

http://www.ahhqi.org/research/efficient-care

Home Health $3,267

Skilled Nursing Facilities $8,981

IRF $13,073

LTCH $27,399

Section 2Improving Care Transitions/Reducing

Readmissions

.

Seamless Transitions

At the time of the first home visit (usually within 24 hours), your patient’s:

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.

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. 

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 patient’s 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

can’t 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 readmissions. 

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 hospitalizations.

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 disorder;

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.

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 crackles.

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.

Home Care Knows Chronic Illness Management

Section 4Managing 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://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf

Diane Meier, Center to Advance Palliative Care

Palliative Care Teams Address Three Domains

1. Physical, emotional, and spiritual distress;

2. Patient-family-professional communication about achievable goals for care and the decision-making that follows; and

3. Coordinated, communicated, continuity of care and support for social and practical needs of both patients and families across settings.

“Don’t ask what’s the matter with me.

Ask what matters to me.”

13.211.1

2.3

9.4

4.6

35.0

5.3

0.9 2.4 0.90

10

20

30

40

Home healthvisits

Physicianoffice visits

ER visits Hospital days SNF days

Usual Medicare Palliative care intervention

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, 1999–2000

Source: KP Study Brumley, R.D. et al. JAGS 2007; Diane Meir, Center to Advance Palliative Care

1) 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 limitation)• Chronic obstructive pulmonary disease (requiring home O2)• AIDS (CD4<200 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  /   No

3) Does the patient demonstrate any of the following unmet needs?  • Guidance with pain and/or non-pain symptom management• Advance Care Planning/Advance Directives issues related to continuing health care needs• Guidance with healthcare decision-making• Bereavement Issues negatively impacting health status• 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.

Adopted from the Beth Israel Medical Center, New York ED Palliative Care Screening Tool; The Center to Advance Palliative Care (CAPC) Website

Hospice/Palliative Care Screening

Home Care Delivers Satisfied Patients

Patient Satisfaction Survey