February #HomeHealthChat: How to work together in the home to improve cardiac outcomes

The February #HomeHealthChat was co-hosted by VNA Health Group (@VNAHealthGroup).

The #HomeHealthChat focused on how to work together in the home to improve cardiac outcomes.

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, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

Guest Blog: An Adapted Cardiac Rehabilitation Program for the Home Care Setting

Cardiovascular disease (CVD) remains the leading cause of death in the United States. Due to significant advances in health care, there is an increase in the number of individuals living with CVD. These individuals may struggle with self-management and symptom control, and 25% patients with heart failure discharged from the hospital are readmitted within 30 days. CVD is a particularly diagnosis common among the home care population, with heart failure (HF) and acute myocardial infarction/ischemic heart disease as leading conditions. Home care clinicians are often the first line of rehabilitation and support for patients post-hospitalization. An adapted home-based cardiac rehabilitation (CR) represents a promising approach to improving care and reducing hospital readmissions among patients with CVD. The services of CR can reduce all-cause mortality and cardiac mortality rates, and benefit patients through exercise and modifications of controllable risk factors. Despite the clinical effectiveness of CR, participation rates in these programs remain low. There is a need for alternate models of secondary preventative cardiac care to increase adherence to CR services and prevent poor outcomes. Home-based programs are potentially an effective and low-cost method of care. However, there are limited evidence-based evaluations that home care agencies are implementing the core competencies of CR programs into their episodes of care and that home care clinicians receive education on these competencies.

Our pilot program, Home Heart Health, is an adapted CR program for the home care setting. Home Heart Health is an interdisciplinary CR program that emphasizes CVD risk factor modification and management for home care patients. In our program, home care registered nurses, physical therapists, and occupational therapists were educated to provide adapted CR services to patients as a complement to traditional home care. This training for home care clinicians was adapted from the American Association of Cardiovascular and Pulmonary Rehabilitation professional core competencies for outpatient CR. It was developed based on literature and guideline reviews, as well as themes identified among patients and clinicians. During the program, patients received visits from these home care clinicians, who provided an exercise plan, nutrition counseling, and self- management education, with accompanying patient teaching tools. Clinicians practiced in accordance with standardized interventions checklists. We conducted a multi-phase study to develop, implement and evaluate this adapted CR program.

The first phase of the pilot was to develop and implement the CR training program adapted for home care clinicians, incorporating the viewpoints of homebound patients with cardiovascular disease. Literature and guideline reviews were performed to glean curriculum content, supplemented with themes identified among patients and clinicians. Semi-structured interviews were conducted with homebound patients regarding their perspectives on living with cardiovascular disease and focus groups were held with home care clinicians regarding their perspectives on caring for these patients. A questionnaire was administered to home care nurses and rehabilitation therapists and compared for pre- and post-training. Three themes emerged among patients: (1) awareness of heart disease; (2) motivation and caregivers’ importance; and (3) barriers to attendance at outpatient CR; and 2 additional themes among clinicians: (4) gaps in care transitions; and (5) educational needs. Questionnaire results demonstrated significantly increased knowledge post-training compared with pre-training among home care clinicians. There was no significant difference between scores for nurses and rehabilitation therapists, indicating the feasibility of interdisciplinary training. As a result of this study, we concluded that home care clinicians respond well to an adapted CR training to improve care for homebound
patients with cardiovascular disease. Clinicians who participated in the Home Heart Health
training demonstrated an increase in their knowledge and skills of the core competencies for CR. Read the full manuscript depicting the development and implementation of the Home Heart Health program and training for clinicians here.

The second phase of the pilot was to conduct a mixed methods analysis to determine the
feasibility and acceptability of Home Heart Health. Surveys measuring patient self-care and
knowledge were administered to patients at baseline and at 30-day follow-up. Semi-structured interviews were conducted with patients and home care clinicians at completion of the program. All survey indicators demonstrated a trend towards improvement, with a statistically significant increase in the self-care management subscale. Qualitative analyses identified three patient themes: (1) self-awareness; (2) nutrition; and (3) motivation; and three clinician themes: (1) systematic approach; (2) motivation; and (3) patient selection process. We concluded that incorporating CR into the home care setting proved to be a feasible and acceptable approach to increasing access to CR services among elderly patients. As acute care transitions to the home and outpatient settings, coupled with efforts to meet patients were they are, studies demonstrating the feasibility of alternative methods to care are vital. Our pilot study supports the need for further testing with a larger sample to determine the efficacy of adapted cardiac rehabilitation for the home care setting. Read the full manuscript examining the feasibility andacceptability of Home Heart Health here.

Please contact Jodi.feinberg@homehearthealth.org with questions or comments!

November #HomeHealthChat: Physical Therapy in the Home

The November #HomeHealthChat was co-hosted by the APTA Home Health Section.

The #HomeHealthChat focused on physical therapy in the home.

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, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

October #HomeHealthChat: Health Information Exchange in Home Health

The October #HomeHealthChat was co-hosted by the Massachusetts eHealth Collaborative (@MAeHC_org) and Home Healthcare Hospice & Community Services (HCS).

The #HomeHealthChat focused on implementing and integrating health information exchange in home health transitions of care settings.

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, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

June #HomeHealthChat: Patient Refusals of Home Health Care

The June #HomeHealthChat was co-hosted by the United Hospital Fund (@UnitedHospFund).

The #HomeHealthChat focused on patient refusals of home health care. The conversation stemmed from the Aliance and United Hospital Fund co-sponsored roundtable report, released in May 2017. You can read the full report here.

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, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

April #HomeHealthChat: Home Health’s Role in Caring for People with Alzheimers and Dementia

The April #HomeHealthChat was co-hosted by the LEAD Coalition (@LEAD_Coalition).

The #HomeHealthChat focused on home health’s role in caring for people with Alzheimer’s and dementia.

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, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

What’s in A Star Rating?

Co-authored by the Alliance and Visiting Nurse Associations of America

Over the past few months, the Centers for Medicare and Medicaid Services’ (CMS) introduction of patient experience survey star ratings to Home Health Compare, as a way to better understand the overall patient experience with care provided through Medicare-certified home health agencies, has gained a lot media attention.

While the jury is still out on the star ratings as a whole, home health agencies recognize that both quality of care and patient experience are critical. Agencies are learning from the issuance of the star ratings and are committed to improving their performance on both quality of care and patient experience.

Outlined below, the Alliance and VNAA breakdown the top five takeaways from the Patient Survey Star Ratings:

  1. The new patient survey star ratings do not replace, but instead are in addition to, the Quality of Patient Care Star Ratings used to describe the quality of clinical care provided by a Medicare-certified home health agency.
  2. Health care is moving towards a system that rewards value over volume and more readily engages consumers; as such, performance data will become increasingly important.
  3. The Home Health Compare Star Ratings are the first step towards streamlining communication regarding home health quality and patient experience in a way that is digestible to health care consumers.
  4. The discrepancies in the patient and quality ratings among individual agencies stem from several factors, including the limitation of the Medicare home health benefit, as well as the understanding of skilled versus non-skilled home health health services. For example, Medicare home health care provides skilled, clinical care, not services such as meal planning and house cleaning. Unfortunately, there is a disconnect for many patients when those needed non-clinical services are not met by their home health care team, despite receiving excellent clinical care.
  5. The patient experience survey is a positive step in the right direction, and is essential to capturing the overall home health care experience, but CMS must refine its metrics to capture more accurate data.

As organizations committed to advancing home health care, the Alliance and VNAA stand ready to work with the Administration to perfect the use of patient survey data so that it is balanced with necessary quality data.

Celebrating Women in Home Health Care

Happy International Women’s Day!

Women are vital to home health care, both as employees and patients, and today we celebrate the contributions of women in the industry and the patients who benefit from their care.

The National Women’s History Museum credits Lillian D. Wald, founder of what is today the Visiting Nurse Service of New York, with inspiring the New York Board of Health to organize the first public nursing system in the world.

Nationally, women are tremendous assets to our healthcare industry, and this is especially true for home health care. In 2014, a whopping 88.6% of persons employed in home health services were women; that’s over a million women employed in the industry! Nationwide, women make up roughly 47% of the workforce, and while women are more likely to work in the health care industry writ large (78.6%), home health care is still even more female-dominated than the industry as a whole. Within the Bureau of Labor Statistics’ “health care and social assistance” industry marker, home health care services employ the second greatest percentage of women.

It’s not just in the workforce where women are prominent. Looking at information from the 2015 Home Health Chartbook, home health patients are also more likely to be women, with females comprising 61.5% of home health users (compared with 54.6% of all Medicare beneficiaries). Women actually comprise a smaller percentage of home health users than males under age 85, but over a quarter of female home health users are over 85.

Diving deeper into the demographics, women are three times more likely than their male counterparts to be widowers, while less than a third are married. Women who receive Medicare home health services are also much more likely than male users to have an income below $25,000 a year.

According to the Kaiser Family Foundation’s 2009 fact sheet on “Medicare’s Role for Women” across the Medicare population, women are more likely than men to suffer from arthritis, hypertension, and osteoporosis. Almost 50% of women, compared with 38% of men, suffer from three or more chronic conditions. That same paper noted that while Medicare plays a critical role for women, women are still more likely than men to spend a greater share of their incomes on medical care. It is therefore crucial to continue finding ways to both ensure funding of the program and new innovation and models to help women face the challenges posed by a rapidly aging population.

Home health care is shaped very much by women, as patients, providers, and innovators. Today we thank them, and look forward to their continued role in molding the home health care delivery system of the future.

Home Health is Where the Heart is

This February, in celebration of American Heart Month, don’t overlook the importance of the home as a critical place of care for those with heart conditions.

A quick look at the most recent year available shows that heart failure, hypertension, and other heart conditions are common among the home health care population.

  • Heart failure and shock (with and without major complication or comorbidity) are the third and fourth most common MS-DRGs for home health Medicare Part A episodes
  • Heart failure is the fifth most common diagnosis (using ICD-9 codes) among all Medicare Home Health claims.
  • Ninety-eight percent of the time on average nationally, home health teams met the quality measure for treating heart failure symptoms.

Nationally, hypertension is the most common chronic condition among Medicare beneficiaries with 27.5 million beneficiaries aged 65+ diagnosed. Other heart conditions, which include coronary artery disease, peripheral vascular disease, and peripheral artery disease, is third, and congestive heart failure is 12th, in front of mental illness/disorder, Alzheimer’s Disease, and broken hips.

The Home Health Quality Improvement (HHQI) National Campaign sheds further light on the common symptoms on a heart attack, as well as some of the risk factors for heart attack and heart disease in a recent blog post.

Given both the preference to age in place and the lower cost to the system home health care affords, more and more Boomers will be receiving home health care in the future. And it turns out, the home can be a critical care provider for many suffering from various heart conditions.

A few years ago, the Alliance did a series of profiles on utilizing new programs and technology to reduce readmissions, all with a focus on heart failure patients. These case studies showed a decrease in rehospitalization rates for heart failure patients using an array of telehealth programs. Interventions in the programs included patient education on how the heart works, care transitions from hospital to home, and telemonitoring measurements.

For instance, in 2007 the Visiting Nursing Association of Western New York began a hospital to home program in conjunction with what was then Cardiocom (now Medtronic Care Management), which utilized telehealth data to track patient progress and identify a need for possible early intervention. The program was instituted for cardiac patients including those with heart failure, hypertension, post coronary artery bypass graft surgery, atrial fibrillation, coronary atherosclerosis, and chronic obstructive pulmonary disorder (COPD). Typically, patients would digitally check-in with weight and blood pressure measurements, as well as a few health-related questions. A telehealth team would receive the information almost instantaneously, and would review whether a patient was following their prescribed medical regime. If the team spotted an issue, they worked with the patient’s physician to make adjustments. During the course of the program, the Visiting Nursing Association of Western New York saw an 11 percent decrease in acute care hospitalizations and high patient satisfaction ratings.

Programs such at the one implemented by VNA of WNY demonstrate one way in which home health can be a vital resource for those with an array of heart conditions. Working hand-in-hand, technology and home health are poised to continue serving many more happy hearts in the future.

Opening the Front Door to Better Care

Published by Huffington Post
By Steve Landers MD,MPH
January 25, 2016

This article is co-authored with Dr. Bruce Leff, Professor of Medicine and Director of the Center for Transformative Geriatric Research at Johns Hopkins@HopkinsMedicine.

America is experiencing a dramatic population shift — one that will turn the country on its head. As Baby Boomers age, more people will live with chronic conditions, like heart disease or dementia, and many will have difficulty with basic abilities like walking and managing their household.

These shifts will create enormous challenges for our country. We must do everything possible to ensure that older Americans remain independent and healthy at home, without experiencing the suffering, indignity, and costs associated with unnecessary hospitalizations and institutionalization.

Our success in answering this call will dictate quality of life vs. suffering for millions of people. The country’s economic health is also at stake as the growing costs of Medicare and Medicaid threaten to squeeze out funding for other priorities. A key to solving this vexing problem is improving access to quality care at home.

In the wake of the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015, we are seeing a shift toward more care coordination and “value-based” care. These trends have led to more interest by doctors and hospitals in helping people succeed in home and community-based settings.

This new attention is a good start, but it’s not enough.

The focus of current reform efforts has centered on insurers, hospitals, physicians, and employers. Home-based care has been left out of high profile national policy conversations, despite the fact that most older Americans prefer to stay at home and “age in place.”

Our policymakers aren’t putting enough time and resources into strengthening home health care and developing new home-based care strategies. Further, some home care policy proposals actually risk hurting the positive programs that already exist.

Out of this leadership void, the Future of Home Health (FOHH) Project was born. Developed by the Alliance for Home Health Quality and Innovation , the FOHH Project has taken on the challenge of starting a national conversation on these issues and the project really picked up steam when the Institute of Medicine (IOM) and National Research Council (NRC) hosted ‘The Future of Home Health Care’ workshop. The summary book and videos from the workshop are available online.

A few overarching themes recurred throughout the workshop, these themes could provide a head start for leaders interested in improving care:

1. There’s no place like home. Stakeholders from many backgrounds called for a shift towards community based care–making the home the center of care whenever possible. Family caregivers at the workshop were especially passionate about the importance of home care.

2. Better care at lower costs. Home health care of the future must be a solution to high costs and quality of care concerns. One example is Medicare’sIndependence at Home Demonstration, which is showing that medical teams that make house calls to Medicare’s sickest and most costly patients at home can support these individuals and save lots of money.

3. Payment policy and regulations need improvement. To build and grow new approaches to home care there will need to be policy and payment changes that support innovation. Many current policies and programs are fragmented and outdated. There should be more coordination, integration, and alignment around addressing both medical and social issues. Several historical policies and programs have created an unnatural separation between medical and social concerns even though high quality care for an aging population requires both to work in concert.

4. Don’t forget about the workforce! We must improve training, especially in geriatrics and palliative care, for all types of health professionals. Developing people to work in team-based care will be key.

5. Technology, technology, technology. Smart use of mobile health, health information, remote monitoring, telemedicine, independent living, and point of care technologies are essential for the shift towards home and community based care.

6. Accurate report cards. Quality and outcomes will need to be measured in order to reflect the value of community and home-based care. We must take care to ensure appropriate quality measures that fit the needs and goals of older people with multiple medical problems, rather than current measures that often focus on single diseases.

The ultimate goal of the FOHH Project is to develop a framework for home health delivery in the future and to take advantage of the many promising innovations that have not been scaled widely due to gaps in policy and for lack of attention.

These efforts serve as a foundation for beginning a discussion, but more national dialogue is required, with input from a wide range of leaders. To truly have a person-centered, compassionate, and responsible healthcare system we must work on building a bright future and prominent role for home health care.