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CONSIDER HOME CARE
Health Cares Cost Effective
Solution
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Section 1
An Overview
Why Home Care?And Why Now?
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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;
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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 improvepatient 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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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..
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Hospital Discharge Disposition - MA
Data: January 2011- December, 2011, Source: Masspro
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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 averagefirst 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
http://www.ahhqi.org/research/efficient-carehttp://www.ahhqi.org/research/efficient-carehttp://www.ahhqi.org/research/efficient-carehttp://www.ahhqi.org/research/efficient-care7/30/2019 Cost Effective Home Care in Massachusetts
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Section 2Improving Care Transitions/Reducing
Readmissions
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Seamless Transitions
At the time of the first home visit (usuallywithin 24 hours), your patients:
Home environment is assessed forhazards that might increase risk of a fallor other injury;
Medications are reconciled andteaching is initiated to supportcompliance; and
Need for referrals for therapy, homehealth aides, &/or social work areevaluated.
Example:
Complications of a late Friday
discharge can be avoided with ahomecare 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.
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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 arenot 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 coordinate
with 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 increasingsymptoms 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 tohelp 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 andmore timely interventions leading to reduced hospitalizations; and
Self management support around management of a chronic illness.
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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 managechronically ill patients.
Home care can be the
extension of the physician
practice, providing the
varied disciplines, patient
education and in-homevisits.
Home Care Knows Chronic Illness Management
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Section 4
Managing AdvancedIllness
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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, andother 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
http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdfhttp://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf7/30/2019 Cost Effective Home Care in Massachusetts
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Palliative Care Teams Address Three Domains
1. Physical, emotional, andspiritual distress;
2. Patient-family-professionalcommunication about
achievable goals for care andthe decision-making thatfollows; and
3. Coordinated, communicated,continuity of care and supportfor social and practical needs ofboth patients and familiesacross settings.
Dont ask whats
the matter with me.Ask what matters
to me.
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13.211.1
2.3
9.4
4.6
35.0
5.3
0.92.4
0.9
0
10
20
30
40
Home health
visits
Physician
office visits
ER visits Hospital days SNF days
Usual Medicare Palliative care intervention
Palliative Care at Home for the Chronically IllImproves 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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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
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78%
78%
79%
79%
80%
80%
81%
81%
82%
82%
State National
82%
79%
Would patients recommend the home health agency to friends &
family?
Home Care Delivers Satisfied Patients
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Patient Satisfaction Survey
83%
84%
84%
84%
84%
84%
85%
85%
85%
85%
State National
85%
84%
How do patients rate the overall care from the home health agency?