Taking Private Duty Home Care to a Whole New LevelHospital Assisted Nurse Discharge Service (HANDS)
and BrightStar Clinical Pathways
The Role of Private Duty Home Care in Reducing Hospital Readmissions &
Enhancing Quality Of Life
The Opportunity
• Hospital/Health System data will be scrutinized at a number of levels and failure to achieve certain national CMS benchmarks will result in
– Financial Penalties • Excessive Readmissions
– Less Robust Rewards• Poor Customer Satisfaction
• Poor Outcomes of Care
As part of the Patient Protection & Affordable Care Act (PPACA), there
are a number of changes that will impact
reimbursement to hospitals and other healthcare systems
National efforts are underway to reduce
potentially preventable hospital readmissions and
optimize the patient experience
*Centers for Medicare & Medicaid
Services, Public Affairs, April 2009
Medicare data shows that nearly 1 in 5
patients who leave the hospital are
readmitted within the next month
and that more than 75% of these
readmissions are preventable*
Research has demonstrated that many
of the return trips can be prevented
with an in-home care program
that includes proper education and
supervision.
Healthcare
systems need to
look for new
solutions since
existing
approaches are
not solving the
problem.
Top Reasons for 30-day hospital readmissions:
Failure to make follow-up appointments
Lack of communication
Failure to understand medication management
Absence of in-home support
Non-adherence to lifestyle recommendations
Failure to understand and actively participate in the
management of their chronic disease
At BrightStar we utilize a Best Practice approach to care
following the National Quality Standards of
The Joint Commission
The Framework: Making More Possible
We are companions on the healthcare journey
our clients take.
BrightStar’s clinical programs allow us to
partner with the client, their family and their healthcare team to
enhance quality of life and improve care
outcomes.
HANDS
BrightStar Clinical Pathways℠
BrightStarLifeCare
KidCare
Staffing
Person-Centered CareClinical ExpertiseNational Quality Standards
Cutting Edge Clinical Programs
BrightStar’s Clinical Pathways ℠ and HANDS
Program was inspired by nationally recognized
care transition programs:
Coleman Care Transition
Intervention Program
which reduced hospital readmissions by
50% at 30, 60 and 90 days
HANDS is a transitional care program focused
on a safe transition home
After leaving the hospital it is important that the patient
have a direct link to an accessible care provider.
HANDS provides that link, bridging the transition to
home and addressing issues and questions that arise.
Medicare agencies may not be able to be there within
the 1st - 24 hours and sometimes not for 2-4 days.
• BrightStar’s Hospital Accelerated Nurse Discharge Service (HANDS) is a transitional care program to facilitate a safe discharge home.
– It is ideally the beginning of a journey we take with the client and their healthcare team.
• It begins at time of discharge and continues for a minimum of 24 hours
– critical transition time for
re-engagement in the home setting.
• A visit by our Registered Nurse Care Manager is the cornerstone of the program
– Assessment, Medication Reconciliation, Disease State Education w/attention to Red Flag Symptoms
• Person-centered services performed by our CNA
– Transportation from hospital to home, Home Safety Check, Light Housekeeping, Retrieval of Simple Supplies (medications, groceries, etc), Light Meal Prep, Transition Check List which includes phone calls to loved ones, arranging/confirming follow-up appointment with discharging physician
HANDS:
What is it to Our
Partners?
• HANDS Basic
– 3 hours CNA time
– 1 RN Home Visit w/i 4-8 hours of
hospital discharge
• HANDS Plus
– Everything included above
– Pre-discharge RN Visit at hospital
(meet & greet, chart review,
discharge instructions, etc)
– 1 additional RN visit
– 24/7 RN phone call availability for
30 days
– Detailed medication
instruction/med set-up if indicated
HANDS Basic Services
HANDS Plus Services
BrightStar Clinical PathwaysEmpowering individuals with chronic illness
through our best practice approach
Simply put…
BrightStar Clinical Pathways ℠ is a
–patient centered
–condition-specific
–transitional care program
Focused on
–reducing negative outcomes
–optimizing quality of life
BrightStar Clinical Pathways SM
Patient Centered
Evidence-based
Condition-specific
Best practice approach
Time-limited (4 wks)
RN Clinical Pathway Coordinator
Specially Trained CNAs
BrightStar Clinical Pathways SM
Heart failure
COPD
Pneumonia
Acute MI
Delirium & Dementia
Diabetes
Falls with Fracture
BrightStar Clinical Pathways℠ Materials
BrightStar Clinical Pathways ℠ : Essentials Package
4 RN CPC Visits, 8 RN CPC Virtual Visits,
13 Specialty CNA Visits
RN Visit
RN Phone Call
CNA/HHA Visit
Week 1
X
X X X
X X X X X
Week 2
X
X X
X X X
Week 3
X
X X
X X X
Week 4
X
X
X X
TTL
4
8
13
25
Each face to face visit is a 2 hour condition-specific person-
centered interaction focused on empowering the client as well
as symptom surveillance
BrightStar Clinical Pathways ℠ MS DRGs and Frailty Factors
*Frailty Factors
• Mult Diagnoses
• Mult. Medications
• ADL/IADL Deficits
• Unintentional Wt Loss
• Limited Support
Frailty Factors*
MS DRG CC
MS DRG
MS DRG MCC
Essentials
Essentials
Plus
BrightStar Clinical Pathways ℠ :Essentials Plus Package
5 RN CPC Visits, 13 RN CPC Virtual Visits,
17 Specialty CNA Visits
RN Visit
RN Phone Call
CNA/HHA Visit
Week 1
X X
X X X X X
X X X X X X X
Week 2
X
X X X
X X X X
Week 3
X
X X X
X X X
Week 4
X
X X
X X X
TTL
5
13
17
35
Each face to face visit is a 2 hour condition-specific person-
centered interaction focused on empowering the client as well
as symptom surveillance
Other Essential Elements of BrightStar Clinical Pathways℠ – Care Together
• Web based communication and calendar tool for the client and their formal and informal care team; also promotes the self-management of chronic illness
– PressGaney/Patient Impact • National Patient Satisfaction Survey
comparable to what many hospitals utilize
– We hold ourselves to a high service standard
– 9 out of 10 clients would refer us to a friend
– ABS 2.0• Data tracking of diagnosis, recent
hospitalizations, reasons for admission/readmission;
• Staff assignment
Building a Platform of
Clinical Excellence
℠Three key ways CareTogether enhances BCPs for clients & their families:
1. Condition specific educational materials, care tools, resources
Families using with physicians and case managers can enhance communication and understanding and adherence!
℠Three key ways CareTogether enhances BCPs for clients & their families:
2. Calendar linked with ABS shows client + Care Team visit dates, times, name and more
3. Keeping the family involved and updated is key part of family and friends supporting the care and “better choices” of the Pathways program
HCAHPS vs BrightStar Press Ganey Surveyhttp://hcahpsonline.org/Files/HCAHPS%20V6%200%20Appendix%20A%20-
%20HCAHPS%20Mail%20Survey%20Materials%20(English)%202-16-2011.pdf
Which questions match between
HCAHPS & Press Ganey?
Discharge
Plan?
Which questions illustrate
opportunities for BrightStar to
help?
BrightStar Clinical Pathways ℠ Foundational Concepts
• Person Centered– The individual is more than the sum of their parts
(or their diseases and medications)
• Patient Empowerment with
Self Management of Chronic Disease
• BrightStar Clinical Pathway℠ Team Leader– Together
– Everyone
– Achieves
– More
Key BrightStar Clinical Pathways℠Coordinator Goals
• Motivate Clients – To become as independent as possible in monitoring
and maintaining their own health status
• Provide Clients with the knowledge and skills – To make informed decisions about their healthcare
and quality of life
• Reduce negative outcomes – Hospitalizations, Readmissions, Urgent Care Visits
,ER Visits, Falls, Med Errors, etc
• Maintain active communication – BrightStar Clinical Pathway Team, Client’s Family and
Physician, Other Healthcare Providers
HF Visit Details: RN & CNA
HF Knowledge Guidebook
HF Red Flag Alert
HF Symptom Tracker
Benefit to Patient:
Continuous care for better outcomes
Earlier DischargeRN education relationship
Reduce risk of falls
Improved medication management
One on one help and guidance in the home
from specially trained CNAs
Additional resources to provide care,
transportation, RX pick up, cleaning, etc
Stay out the of hospital and the ER
What this program will mean to
Healthcare Systems & Providers:
Improved Communication
Improve flow of information between hospital, 0utpatient physicians and provider.
Better Patient Outcomes
Identify high-risk patients and target specific interventions to mitigate their risks for adverse events. With timely post discharge in-home care management and follow up.
Improve Efficiencies
Complements patient and family preparation for discharge. Ensure a timely, efficient and safe discharge and transition to home.
Better Image
Improve patient and public perception of care and result in higher satisfaction scores. Promote customer loyalty & confidence in St. Mary's and enhance patient overall experience.
Reduce likelihood of potentially
preventable and costly readmissions
Why BrightStar?
Our Difference: Joint Commission Accreditation
Fully Licensed by the
Press Ganey satisfaction survey
Licensed and insured for transport
RN DON trains & competency tests
all CNAs
All patients receive in-home risk
assessment to help reduce falls
Continuity of care and care
collaboration
Ongoing services to maintain safety
and success
Commitment to RN oversight
Person centered approach
CareTogether®
Flexible & responsive
Highly qualified and specially trained staff
Stringent screening and employment
practices
HANDS
BrightStar Clinical Pathways
Locally owned & operated
