The Role of Home Health in Reducing Acute Care Hospitalizations: An Agency Case Study

1. The Role of Home Health in Reducing Acute Care Hospitalizations: An Agency Case Study Kathy Kufta RN, BSN CEO / Administrator Complete Home Care, Inc.

2. Care Transitions . . . • The movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Care Transitions InterventionSM , Eric Coleman, MD, MPH

3. “Care transitions is a team sport, and yet all too often we don’t know who our teammates are, or how they can help.”-Eric Coleman, MD, MPH

4. Home Health is on your team!

5. ACH CUTE ARE OSPITALIZATION THE FACTS

6. Acute Care Hospitalizations . . . • Cost about $ 3506 per day • Have an average LOS of 5.9 days • Occur much more frequently for patients with chronic conditions • Occur in 1 out of 4 home health pt. episodes

7. Medicare Readmissions: WE ARE BEING WATCHED . . . • Unplanned Readmits cost $ 17,000,000,000 (BILLION)/YR • Half don’t see Physician before 30 day readmit • Readmission is most often due to another condition or complication SOURCE: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009Apr2:360(14);1418-28.

8. Medicare Payment Advisory Commission (MedPAC) • 19.6% or 1/5 of 12 million Medicare beneficiaries in 2003 or 2004 were re-hospitalized within 30 days of discharge from the hospital • Up to 76 % of these readmissions may be preventable • 64% of those readmitted, received NO post-acute care between discharge & readmission – home health underutilized * MedPAC June 2007 report to Congress

9. A New England Journal of Medicine study . . . Found that in 2003-2004, 1/3 or 34% of discharged patients were rehospitalized within 90 days

10. Shocking news . . . • Of all of the patients in the NEJM study who were re-hospitalized, only 9% were homecare patients! FACT: HOME HEALTH CARE CAN MOST DEFINITELY HELP DECREASE HOSPITAL RE-ADMISSIONS

11. MedPac study 2007 discovered . . . “Patients’ adherence to discharge instructions also affects hospitals’ readmission rates” We need to make sure that knowledge sharing between clinicians and patients and their families is maximized – IMPROVED COMMUNICATION!!

12. AVOIDABLE HOSPITAL RE-ADMISSIONS ARE . . . • A QUALITY PROBLEM • A SAFETY PROBLEM • THE MOST IMMEDIATELY ACTIONABLE DRIVER OF EXCESSIVE COSTS

13. Common reasons people return to the hospital after discharge: PROBLEMS HOME HEALTH CAN 1) Reconcile meds and communicate with physician’s office 2)Encourage pt. to keep appt. and help arrange transportation 3) Teach pt. RED FLAGS & communicate immediately with physician’s office or Care Manager 1) Problems with medicines 2) Not getting a timely follow-up visit with physician 3) Not recognizing early signs of trouble OR RED FLAGS! Home Health can intervene and help to resolve all of these issues!

14. FACTS: • Through the use of best practices and home care, these hospitalizations and expenses may have been avoided • Increased hospitalizations for patients can translate into decreased reimbursement for physicians (Medicare and private insurances)

15. FACT:

16. Best Practices: • Evidence-based practice • techniques or methodologies that, through experience and research, has been proven to reliably lead to a desired result. (ie. good health outcome) • WHAT WORKS! • Best Practice Intervention Package (BPIP) - Home Health Quality Campaign, Quality Insights

17. The WINNING EQUATION . . .

18. Current State of Post-Acute Care- Fragmentation and Practice Variation are Barriers to Quality & Efficiency V A L U E ONGOING CHRONIC CARE ACUTE CARE POST ACUTE POST-ACUTE CARE AT HOME

19. The missing puzzle piece . . . Teaching the patient HOW to get well and stay well! (SELF-MANAGEMENT SKILLS) Home Health Care can do this!

20. Do Home Care Interventions Reduce Readmissions? REFERENCES: Phillips CO et al.”Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.” JAMA.2004 Mar17:291(11):1358-67. DESCRIPTION: Pooled analysis of 18 randomized controlled clinical trials RELEVANCE TO HOME CARE: 11 OF 18 TRIALS INCLUDED HOME VISITATION RESULTS: After mean follow-up of 8 months with home visit intervention had lower readmission rates - 35% vs 43% Subgroup of trials with home visit performed better

21. How Can Home Health Help? Acute care hospitalization may be avoided if the home health nurse. . . • adequately checks the patient's health condition at each visit to detect problems early. • assesses the patient's ability to eat, drink, and take medication, and to live safely in their home. • coordinates the patient's care by regularly communicating with patients, informal caregivers, doctors, and other care providers.

22. Home Health Care can… • Provide skilled physical assessment • Teach the patient and/or their family daily skills to manage their disease (1:1) SELF-CARE • Communicate with the Medical Home worker to alert them of potential problems –RED FLAGS • Provide resolution for the identified problem and prevent hospitalization • Provide medication reconciliation (make sure the patient is taking the right meds) • Set up pre-filled med boxes/syringes with pharmacy

23. Medicare covers home health if . . . • There is an intermittent skilled need (wound, IV, diabetes skills, Med management, unstable physical status, ambulation dysfunction) • There is a doctor’s order • The patient is homebound – (def) pt does not leave home frequently or for long periods and has difficulty leaving the home

24. Homebound means. . . • there is a normal inability to leave home and, therefore, leaving home requires a considerable and taxing effort. • Pt may be SOB, have poor endurance, or have ambulation/movement difficulties -”Coverage Guide for Home Health Agencies”, Medicare Reference Guide, August 2006,CMS Pub. 100-2, Ch.7 , §30.1

25. Homebound Criteria 1 • Patient’s medical condition restricts the ability to leave home without the assistance of another individual or without the assistance of a supportive device (cane, walker, wheelchair) -”Coverage Guide for Home Health Agencies”, Medicare Reference Guide, August 2006,CMS Pub. 100-2, Ch.7 , 30.1

26. Homebound Criteria 2 • Patient leaves home only to receive medical treatment that generally cannot be provided in the home OR leaves the home infrequently; for short periods for non-medical purposes or to attend a religious service or unique event. -”Coverage Guide for Home Health Agencies”, Medicare Reference Guide, August 2006,CMS Pub. 100-2, Ch.7 , 30.1

27. Patient is still considered to be homebound if he/she. . . • goes to adult day-care • goes to religious services • goes to get their hair done infrequently • goes to unique events such as family reunion, funeral or graduation as long as absences are of short duration

28. Patient is not homebound if he/she: • goes to work • goes to a Senior Center • goes out to eat every day • goes on trips, bingo or to the casino THESE PATIENTS WOULD NOT BE COVERED UNDER THE HOME HEALTH MEDICARE BENEFIT

29. Care Managers can: • Check patient post-discharge for signs of non-compliance or lack of knowledge about their care /meds and for insufficient support for self- management in the home. • Intervene immediately, if necessary • Set up F/U appt with physician within 1 week and refer to HOME HEALTH if needed.

30. Individuals with at least one of the following should be considered for home care: • Cognitive Impairment • COPD • Diabetes • Frequent Hospitalization for any cause • History of depression • Low Output state (classic CHF symptoms) • Multiple Active co-morbidities • Persistent New York Heart Association Classification III or IV symptoms • Persistent non-adherence to treatment regimens • Renal insufficiency *Excerpted from Iowa Health System standardized protocols for patients with heart failure

31. Medical Home Guidelines • RIGHT CARE • RIGHT PATIENT • RIGHT SETTING • RIGHT INSTRUCTIONS • Physician is the “Quarterback” of the team • Medical Home Worker / Care Manager is the coordinator of care • “ the communicator / organizer”

32. Medical Home Model Provides . . . • Better quality of care at a lower cost • Decreased ACH • More preventative care • Better coordination of care

33. Medical Home Guidelines • Identify those discharged patients who are at a greater risk for re-hospitalization • Make 1st contact with pt post D/C within 48 hours -did the pt. pick up their meds? are there signs of non-compliance? are they confused about their meds ? assess if pt needs and is agreeable to home health • Make f/u Physician appt. within the week if possible • Maintain ongoing communication & follow-up re: patient (verbal vs. electronic or both)

34. Our Challenge- working together we can . . . • Decrease healthcare spending by decreasing volume and utilization of services, specifically ACH, while achieving positive patient outcomes.

35. Complete Home Care : A Case Study of Care Coordination and Decreasing Acute Care Hospitalizations

36. Our Success: ACH Rate by 41% !!

37. This is how we did it!

38. Complete Home Care • We have been extremely involved in implementing our own ACH Program, in conjunction with Quality Insights of PA (QIO) since 2004 • In 2005, we were 1 of 3 agencies in PA chosen to participate in a pilot program using telehealth to decrease ACH

39. Complete Home CareACH Telehealth Program • Identifies patients at risk on admission by completion of our self-designed Hospital Risk Assessment FormSEE APPENDIX A • Risk factors were derived from actual agency patient population statistics • Score obtained from this assessment determines telehealth eligibility

40. Our patients are more likely to be rehospitalized if they: • Are poor and live alone • Came to home care from an inpatient facility • Had higher functional deficits in ADL’s • Had difficulty managing meds • Experienced difficulty breathing • Had more than 2 secondary diagnoses • Were admitted to home care with Dx of diabetes, cardiac or chronic skin ulcers without a self-care management plan in place * Based on a case study of Complete Home Care patients (2006)

41. Patients Identified at Risk for ACH and Eligible for Telehealth • Receive front loaded home health visits in the first 2 weeks after admission • Receive telephone monitoring calls from home health nurses on designated days in-between when nursing visits not made, including weekends

42. Receive individualized teaching, counseling and tele-triage, if necessary during the telephone monitoring call • Receive a PRN nursing visit, if warranted, or physician may be notified of any adverse condition identified during the call

43. Emergency Procedures • Complete Home Care has incorporated Emergency Access Information into every pt. admission packet • Patients are instructed to call Complete Home Care FIRST for any problems, unless chest pain (unresponsive to meds) or severe SOB occurs when they are told to go directly to ER

44. Emergency Procedures • Are reviewed and reinforced at every nursing visit to remind the patient that we have nursing staff (RN’S) available 24/7 to address any problems or concerns • All emergency calls are handled quickly and PRN nursing visits will be made if necessary to manage the situation at home

45. Emergency Procedures • Every attempt will be made to manage the patient situation in the home through communication with the physician or Medical Home / Care Manager • CHC staff are proficient with high-tech skills that may be needed to treat the pt. at home (IV’s, pulse ox, KCI VAC etc.)

46. CHC Outcomes in Acute Care Hospitalizations ** Remember lower numbers are better here!!

47. ACH Home Health Compare - CHC %

48. Other Measures CHC uses to Decrease Hospitalization Rates

49. Electronic Medical Record • Each nurse has a mini-laptop that is able to access all patient information and our clinical software system from the patient home • Patient data can be monitored and modified in “real-time” connecting what is currently happening with the patient to our office system

50. Electronic Medical Record • Nurses have the ability to access Internet resources right from the patient home to look up meds, disease-related information and patient teaching. • Nurses can access pt. current med list and labwork • This helps to greatly improve the value and quality of patient assessment & teaching at each nursing visit.