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January #HomeHealthChat: Home Health and Private Duty


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Prioritizing Care From Hospital to Home

Last week, the Washington Post published the heartbreaking story of Joyce Oyler, a home health patient who passed away after receiving the wrong medication; an error which failed to be caught at all levels, including home health. Ms. Oyler’s story is a terrible reminder of the critical nature of care transitions from setting to setting.

Care transitions are a central area of both focus and improvement for the home health care community. Recognizing the importance of quality and safety issues in the transition from hospital to home, the Alliance developed the Home Health Model of Care Transitions. The model lays out an evidenced-based approach to successfully complete a transition and prevent rehospitalization. The model specifically emphasizes medication management as a core component of an effective care transition, and specifies that a home health agency identify the name of each drug prescribed, what it’s used for, dosage, and when and how often the patient should take each medication. Medication allergies and pharmacy name and phone number should also be listed.

Other organizations are also dedicated to putting care transitions at the forefront of emphasis. For instance, the Visiting Nurse Associations of America (VNAA) compiled the Blueprint for Excellence, which features a module of patient safety including medication reconciliation. The Blueprint defines medication reconciliation and adherence, outlines the impact it has one patient outcomes and safety, and identifies best practices for medication reconciliation and adherence in the home. You can access the VNAA Blueprint for Excellence guidelines and resources on medication reconciliation here.

Federal initiatives are further driving quality improvement and patient safety in home health. Just recently, the Centers for Medicare and Medicaid Services (CMS) began assigning Home Health Star Ratings for quality and patient experience, on top of the existing publicly reported quality measures on Home Health Compare.

Star ratings are one mechanism to help consumers access better quality and patient preferred outcomes in home health care, however a number of additional models are currently being implemented to drive home the idea of value over volume in care. The Home Health Value Based Purchasing Model is tying payment to performance, while bundled payment arrangements and accountable care organizations are using payment models that seek to incentivize efficiency.

At the end of the day, policymakers, home health agencies, hospitals, and patient advocates must work collaboratively on ways to best tackle gaps in care from hospital to home.

Preventing tragic deaths, such as Ms. Oyler’s, is so critically important. We simply need to do better for patients and their families. Federal policy initiatives are paving the way, and the work of the Alliance, VNAA, and others are helping by addressing, compiling, and disseminating evidence-based practices and tools.

Together we as an industry and community can work to prevent critical medication errors, hospital readmissions, and most importantly, unnecessary patient deaths.

Street Medicine Brings High-Quality Healthcare to the Homeless

Home health care most often occurs in a rather obvious location: a patient’s home. What though happens when a patient doesn’t have a traditional home? Enter street medicine, an emerging model that delivers care to patients where they are, be that in shelters or in the streets, in an effort to improve public health and care for some of the country’s most vulnerable patients.

Street medicine is, in many ways, similar to traditional forms of house calls, with a physician or physician assistant treating a patient where they live. The difference is the location, and sometimes the transitive nature of the patients.

A mostly grassroots model, a few health systems are keying in to the benefits of street medicine, while the Department of Veteran’s Affairs also already employs a similar model. The VA’s program, Homeless Patient Aligned Care Teams (H-PACT), serves over 5,000 patients a year in 31 locations.

One of the pioneers of street medicine, Dr. Jim Withers, founded Operation Safety Net more than 20 years ago within Pittsburgh Mercy Health System. Operation Safety Net offers a number of focused initiatives for homeless patients, treating the patient as a whole through partnerships with the area agency on aging, the VA, shelters, food banks, and more. The innovative program trains more than 100 residents and students each year and offers a one-month residency for University of Pittsburgh School of Medicine fourth-year students.

Lehigh Valley Health Network also runs a street medicine program, led by physician assistant Brett Feldman. Feldman, who was recently profiled by the Associated Press, treats about 100 patients a month in the program.

What these programs have in common is reduced rates of emergency room visits saving hospitals and health systems money while improving the overall health of the communities they serve. Estimates have shown a decrease in 30-day readmission rates at Lehigh Valley hospital down to 13 percent from 51 percent. Add to that the fact the rate of uninsured homeless has gone up nearly three fold from 24 percent to 73 percent and that’s a lot of savings for the hospital and health system. Many of the other health systems discussed in the AP article have seen similar savings and outcomes improvement.

Just like traditional home health providers are increasing their focus on preventative care, street medicine seeks to treat repeat patients before they wind up in emergent care, where care delivery is much more costly. Focusing on preventative care, and treating patients where they can be or need to be treated is a critical piece for the future of health care delivery. Street medicine, like home health care, aims to reduce readmissions and provide high-quality healthcare that truly serves the patient, especially those who are most vulnerable.

Improving Health Care for All This April and Beyond

April marks the Department of Health and Human Services’ Minority Health Month for 2016, focusing on “Accelerating Health Equity for the Nation.” As a critical piece of the health care system, home health care is a vital ally in the mission of improving health equity.

Data from the Alliance’s 2015 Home Health Chartbook shows that home health care already serves a disproportionate share of racial and ethnic minority patients as compared with the general Medicare population. However, there are still plenty of areas of focus with regard to health equity in home health care. Black and Hispanic home health users are more likely to have an income under 100 and 200 percent of the federal poverty level compared to all Medicare home health users, as well as being half as likely as all Medicare home health users to have an income over $25,000 per year. On top of that, both black and Hispanic home health users are more likely to have two or more activity of daily living limitations.

Work is being done to improve home health care for all, and a number of providers are already utilizing innovative programs to improve care for minority patients. In 2014, the Alliance released a Faces of Home Health profile highlighting the racial and ethnic diversity of home health patients and how one agency is meeting the needs of such patients. The profile featured Asian American Home Care, an agency based in Oakland, California, serving a diverse array of patients. Staff at AAHC speak nine different languages and have extensive knowledge of, and sensitivity to, cultural, ethnic, and racial diversity. Staff undergo training courses and are offered teaching materials in a variety of languages, meeting once a month to coordinate patient care. It’s not just languages in which AAHC staff are fluent. Emphasis is placed on being sensitive to unique considerations for minority patients in many areas of communication, including non-verbal communications, dietary customs of various cultures, understanding political and natural disasters that patients may have endured, and financial and socioeconomic barriers to care. Taken in combination, these specialized skills and tailored approaches help provide more well-rounded care to minority patients, improving overall health care and increasing the likelihood of adherence to care plans and improved outcomes.

Specifically, the profile shares the story of a 91-year old native Chinese speaker being treated by AAHC who prefers Traditional Chinese medicine (TCM) to Western medicine. The patient’s nurse utilized a series of tools to help improve the patient’s care, including making flash cards for her patient to use with doctors to address the language barrier, and finding dietary substitutions that improve the patient’s condition while still maintaining a sensitivity to the customs of the patient’s culture. These small things had a tremendous impact on the patient’s overall health, while still maintaining empathy for the patient’s culture and preferences.

Tailoring care to include cultural, ethnic, and racial sensitivities is vital to not only achieving better clinical outcomes, but to truly providing patient-centered and patient-preferred care. In doing so, home health care can continue to strive toward health equity, and improved patient outcomes and experience. The quicker health equity is achieved for all, the better we all are.

More information on National Minority Health Month is available online at: http://minorityhealth.hhs.gov/nmhm16/. Follow on Twitter using #NMHM16.

New Research and Initiatives Pave Way for Better Home Health Care for All

A few weeks ago the Huffington Post highlighted some new and emerging models of home care being utilized by the Visiting Nurse Service of New York. Some of these models involve treating chronic conditions, such as congestive heart failure (CHF), including front-loading visits in the first week and an evidence-based screening tool.

Additionally, the VNSNY is looking at the demographics of home health users in order to discern ways of providing higher quality, more patient-centered care. One new study looks at language barriers between patients and nurses, while another focuses on access to care for LGBT patients.

To read the full article, click over to the Huffington Post here!

March #HomeHealthChat: Interdisciplinary Teams

The March #HomeHealthChat was co-hosted by the ElderCare Workforce Alliance (@ElderCareTeam). The ElderCare Workforce Alliance is a group of 31 national organizations, joined together to address the immediate and future workforce crisis in caring for an aging America.

The #HomeHealthChat focused on Interdisciplinary Teams.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director of Communications and Events Jen Schiller here.

Below are some of the highlights from the chat:

Low 30-Day Readmissions from Home Health Signal Positive Results for CJR Model

Current research on major joint replacement points to successful uses of home health care as the post-acute care setting for patients. Merits of home-based care include reduced cost, improved clinical outcomes, and increased patient satisfaction. Now, with the recently introduced Centers for Medicare and Medicaid Services Comprehensive Care for Joint Replacement (CJR) Model, which will begin on April 1 of this year, home health sits at the forefront of providing cost-effective and high-quality patient care for patients following hip and knee replacements.

The low rates of 30-day readmission for patients with MS-DRG-470 (major joint replacement) (the 30-day readmission rate nationally is 3.54% from home health, compared with 6.83% from skilled nursing facilities), make the benefit of home health, especially after hip and knee replacement, crystal clear and should help CMS and those participating in the CJR Model to better understand the best means of treating patients.

Knee replacements are one of the most common surgeries performed on Medicare beneficiaries, underscoring the need to develop models that improve patient care delivery, including enhanced efficiencies and reduced costs. Nationally, nearly 10 percent of total home health Medicare Part A home health claims are for patients receiving care after a major joint replacement or reattachment of lower extremity without major complications of comorbidities. Among home health claims, major joint replacement is over three times more common as an MS-DRG than the next most common MS-DRG. In 2013, almost 200,000 home health Part A claims were filed nationally for patients after hip and knee replacements, signaling a need for high quality, safe, and cost-effective models of care after such orthopedic procedures. According to the Clinically Appropriate and Cost-Effective Placement report from 2012, when home health agencies are the first setting of care, Medicare sees an average of over $5,000 in cost savings for each MS-DRG 470 patient’s episode (defined as inpatient hospitalization and the 60 days post-discharge).

In addition to the clinical and cost savings benefits above, recovery and therapy in the home setting allow clinicians to address the unique needs of individual patients, make families feel more comfortable in assisting with care, and assists patients to more quickly resume activities of daily living, such as bathing and dressing. The Cleveland Clinic Model for Home Care After Knee Replacement, profiled in the Cleveland Clinic Journal of Medicine supplement article, “In-home care following total knee replacement,” provides an excellent example for the future success of the CJR Model.

The article outlines The Cleveland Clinic Total Knee Care Path, an integrated care approach, emphasizing home health care in discharge planning and care transitions. Patient and family education is critical and should begin early and remain consistent. The following goals are emphasized in the Cleveland Clinic program:

  • Shared decision-making
  • A home care environment that includes support of family and friends
  • Patient and family education to enhance shared decision-making
  • Return to the home environment as soon as it is deemed safe
  • Elimination of unnecessary or duplicative treatments, tests, or interventions
  • Acceptance of multiple plans or paths in response to changing clinical conditions

In the 10 years since the Cleveland Clinic has integrated home health care into recovery from a total knee replacement, results have been very positive, including a reduction in the average acute care hospital length of stay, increased discharge to home rates, reduced readmission rates, and lower costs to the overall system. In fact, patients discharged to home use fewer resources and cost the system one third as much as patients who receive inpatient post-acute care. Discharge to home rates rose from 32 percent to 74 percent, and hospital stay length decreased by an average of almost one full day, saving money by limiting longer facility stays.

The CJR Model represents a step forward in promoting quality care for patients, as the home is, when clinically appropriate, an ideal setting for patients after an acute care stay when coupled with skilled home health care services. By looking at the readmissions and cost data, along with the successful CCJM Model, we can get a clearer picture of the ways of home health can be utilized to maximize outcomes, reduce cost, and improve patient experience.

January #HomeHealthChat: Home Health and Mental Illness

The January #HomeHealthChat was co-hosted by the Visiting Nurse Association of Ohio (@VNAOhio). Visiting Nurse Association of Ohio is a not-for-profit home healthcare and hospice organization.

The #HomeHealthChat focused on Home Health and Mental Illness.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director of Communications and Events Jen Schiller here.

Below are some of the highlights from the chat: