Consider Home Care

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Health Cares Cost Effective Solution

• Consider Home Care

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Section 1 An Overview Why Home Care? And Why
Now?
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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.  
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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.

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Together We Have a Lot of Work To Do
Source Medicare Hospital Quality Chart Book,
2012
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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.
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Hospital Discharge Disposition - MA
Data January 2011- December, 2011, Source
Masspro
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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
http//www.ahhqi.org/research/efficient-care
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Section 2Improving Care Transitions/Reducing
Readmissions
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. 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.
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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.
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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.

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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.

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Section 3Managing Chronic Illness
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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.

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A Picture Tells the Story
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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.

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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
  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.
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Section 4 Managing Advanced Illness
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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-palliati
  ve-care.pdf
• Diane Meier, Center to Advance Palliative Care

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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.
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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
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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
  limitation)
• 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
  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.

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Home Care Delivers Satisfied Patients
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Patient Satisfaction Survey