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.

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Guest Blog: Thanking Family Caregivers Starts with Family-Centered Care

In honor of Thanksgiving and National Family Caregivers Month, Gail Hunt, President and CEO of the National Alliance for Caregiving shares her thoughts of the importance of family caregivers in the delivery of home health care.

Note: This post originally appeared on LillyPad here.

You’ve gathered your closest friends and family and the table is set for Thanksgiving. This is a moment of gratitude. Consider, in that moment, that someone around the table may one day be your family caregiver. Maybe you will care for them. (Maybe you already do.)

Each year, we give thanks for caregivers during November as part of National Family Caregivers Month. This month in particular we’ve been thinking about what happens when “Care Comes Home.” We talk about the benefits of home- and community-based care in reducing costs and meeting patient demands. But have we discussed the impact on family caregivers when health systems move to home-based care?

Many families rely on home-based care, including the short-term Medicare Home Health Benefit and long-term programs like the Veterans Administration’s Home-Based Primary Care. Others depend heavily on home health aides and telehealth to provide in-home care support. These are critical tools that help aging and medically complex patients live with dignity and independence in their homes.

But as demand continues to grow, policymakers should be aware of the need to better support caregivers who are the backbone of these models. Research has shown that a majority of caregivers help with at least one Activity of Daily Living (such as the daily bathing or dressing of a loved one). Many help with more. Caregivers have also reported that they conduct medical tasks within the home, which can be a source of tremendous anxiety. If the goals of healthcare reform include better managing care transitions, avoiding hospitalizations, and improving chronic care management, then it’s time to start talking about how family caregivers can be part of the answer.

There are several high-impact solutions for policy makers to consider:

  • Include family caregivers as part of the healthcare team. This means implementing “patient-and-family centered care”, collecting caregiver-reported outcomes, and noting the family caregiver in the medical record (both electronic and paper).
  • Assess the caregiver and provide training for caregivers during care transitions. Caregivers are often expected to provide support for health needs, personal and household care, and emotional support following the discharge of a loved one from the hospital. Clinicians should be cognizant of the role that caregivers are being asked to play and be sure to assess the willingness and ability of the caregiver to take on this role before discharge.
  • Develop better technologies to support patient health at home. Two key areas to think about: medication management and care coordination. Family caregivers can be partners in this, but teaching them how to use the tools and communicate with clinicians will be key to making telehealth programs more successful.

Next year is the 2015 White House Conference on Aging and the 50th anniversaries of the Medicare and Medicaid programs. It’s a perfect time to start talking about whole-system health that addresses not just the needs of the patient, but those family and friends who support them. Let’s show our thanks but recognizing both the contributions that caregivers make to our society and how these contributions can enable better healthcare at lower costs.

Gail Gibson Hunt is President and CEO of the National Alliance for Caregiving. Established in 1996, the National Alliance for Caregiving is a nonprofit coalition of national organizations focused on advancing family caregiving through research, innovation and advocacy. To learn more, please visit

Connecting Home Health Care to the Care Continuum: Thoughts from Pamela Duncan, Wake Forest Baptist Medical Center

Recently, the Alliance for Home Health Quality and Innovation profiled healthcare innovator Pamela W. Duncan, Ph.D. as part of the new Revolutionizing Healthcare-at-Home series, in an article titled, “Connecting Home Health Care to the Care Continuum.” One of the goals of this new series is to showcase how the innovative use of home health can improve the lives of patients and improve healthcare outcomes.

Dr. Duncan currently serves as a professor of neurology at the Sticht Center on Aging, Geriatrics & Gerontology at Wake Forest Baptist Medical Center and an Innovation Advisor for The Center for Medicare & Medicaid Innovation. Her most recent project for the CMS Innovation Advisors Program focuses on transitions for patients with congestive heart failure, looking at streamlining the transition between hospital and home health.

Article Highlights

  • Dr. Duncan’s work looks at health care in the context of a cohesive community of care, with home health playing a significant role in a patient’s disease management and the transition from hospital to home.
  • As the intermediary in the transition, home health offers both clinical care and connections to community resources—critically linking acute care treatment with at-home recovery.
  • While the data from the program is still new, Dr. Duncan says she has seen significant reductions in rehospitalizations using cross-continuum collaboration.
  • Creating transitional care programs like the one implemented by Dr. Duncan may help providers and health systems save time, energy, and money while improving patient outcomes.
  • In order to better utilize home health for care transitions to primary care and community-based resources, Dr. Duncan suggests that home health providers should place a greater emphasis on education and improving relationships with other members of the care continuum.

To read the full profile, please click here.

When Being Disruptive at Home is a Good Thing

Guest Blog: Dr. Jack Lewin, Lewin and Associates, LLC

This month, we’re featuring Jack Lewin, Chairman of the National Coalition on Health Care, as our guest blogger. Dr. Lewin is a primary care physician trained in internal medicine with experience in medical practice, public health, hospital leadership, health policy, and association leadership. He previously served as the Chief Executive Officer for the American College of Cardiology and currently serves on the board for the eHealth Initiative at the National Coalition on Health Care. 

It’s common knowledge among health policy insiders that reducing unnecessary hospitalizations and rehospitalizations is where the big savings in health care expenditures will be achieved. However, as long as hospitals are paid on a volume of admissions basis, there is little financial incentive for hospitals and/or hospital-based physicians to reduce preventable admissions and hospital-based services. That’s why all the policy wonks want doctors like me—and the hospitals with which we work—to shift to new payment models that reward better outcomes at lower costs (“value”): models where the lower costs will largely be generated by reducing unnecessary hospital care.

Medicare has begun penalizing hospitals that have higher rates of re-admissions. In many parts of the country, 30% or more of Medicare patients discharged from the hospital bounce back within 30 days; comparing similar populations of patients in some settings, that number can be as low as 10%. There’s a lot of variation, mostly related to the care and support people receive after they leave the hospital. In my view, the most disruptive innovations coming in the health care of the future will not be the amazing and beneficial developments forthcoming in genetics, genomics, pharmacology or new technology. Rather, I see the big game-changer coming from the application of these kinds of things to the redesign of personalized care models for people at home, in the workplace, and in the community. New models of patient-activated care at home—for prevention, wellness, and disease management—are the future of reducing hospital costs, and health care costs in general. Home care innovation is the most disruptive innovation out there!

It won’t be just hospital care that new models of care at home will radically affect: doctors’ office and outpatient clinic visits will be reduced as well. My friend, San Diego-based cardiologist and author, Eric Topol has widely shared his view that the majority of doctor’s office and clinic visits for established patient-physician relationships are unnecessary and can be replaced with new virtual visits and clinical communications using e-mail and person-to-person video-connections at home and at work. (A video of his interview on Rock Center with Brian Williams may be seen here.) Over the past few years, Kaiser Permanente has reduced outpatient clinic visits by 25% by encouraging more secure e-mail communication with beneficiaries and their caregivers. This kind of care model is more convenient and efficient for everybody, when appropriately applied. Virtual visits, home bio-monitoring, and health apps using mobile devices, will allow doctors, nurses, patients, families and caregivers to be clinically connected more conveniently and effectively—at home and/or in the workplace. I predict that even most medical specialist consultations will occur virtually in the not so distant future.

Even for very sick people, home care will play a much more prominent role. I serve as Chief Medial Officer for an exciting new start-up company called Clinically Home, which is rolling out a novel ‘acute-care-at-home’ model. As part of the model, emergency room or clinic patients being admitted to the hospital, and who meet carefully researched clinical criteria, are offered the option of getting their full-service ‘hospital’ care at their instantly hi-tech-equipped home. We estimate that about 20-25% of people admitted to the hospital in most settings could more comfortably and safely be treated and closely monitored for many clinical conditions at home. In addition to reducing hospital stays, new home care models will increasingly be able to prevent avoidable emergency room visits and admissions to long-term care facilities.

Health care needs to continue to be a personal and intimate experience; but today the primary care doctor is often disconnected from—and often even unaware of—their patient’s admission to the hospital. The inpatient may see a different hospitalist they don’t know on each shift, and scary infectious agents living in hospitals pose a threat to patients. If one doesn’t absolutely need to be in the hospital, why be there? We overuse hospitals, in part, because we don’t have hi-tech, hi-touch, high quality, team-based care-at-home models up and running where most of us live—yet. Hospitals, emergency rooms, doctors’ offices, and long-term care facilities remain vitally important parts of health care’s future, but we need to find ways to improve outcomes, patient satisfaction, and disease prevention and management more consistently and efficiently. Home and community-based care is a critical and under-envisioned key to actually achieving those goals.

The Alliance would like to thank Dr. Lewin for his time and insight.  If you would like to recommend a guest blogger for the Alliance, please contact the Alliance’s Director of Strategic Initiatives & Communications C. Grace Whiting, at

Alliance and Cleveland Clinic Journal of Medicine Host Capitol Hill Briefing

Guest Author: Steven Landers, MD, MPH
President and CEO, VNA Health Group
Board of Directors Chairman, Alliance for Home Health Quality and Innovation 

This past Tuesday, I had the privilege to moderate a Capitol Hill briefing as part of a collaboration between the Alliance for Home Health Quality and Innovation and the Cleveland Clinic Journal of Medicine. The briefing focused on home health and its overall value to the health care delivery system, through a discussion on a supplement and corresponding Clinical Medical Education (CME) program in partnership with the Cleveland Clinic.

The supplement, titled, “Optimizing Home Health Care: Enhanced Value and Improved Outcomes”, compiles articles from distinguished physicians, nurses and academics, who are experts in delivering health care at home. This research represents the Alliance’s support of peer-reviewed work demonstrating how home health can be used more effectively to address patient needs, improve outcomes, and lower costs in the Medicare system.

Fellow panelists included:

  • Peter Boling, MD, Chair, Division of Geriatric Medicine, Virginia Commonwealth University
  • Michael Fleming, MD, FAAFP, Chief Medical Officer, Amedisys, Inc.
  • Mark Froimson, MD, MBA, President, Euclid Hospital, Cleveland Clinic Health System
  • Eiran Gorodeski, MD, MPH, Heart and Vascular Institute, Cleveland Clinic Executive Director
  • Margherita Labson, RN, MSHSA, CPHQ, CCM, Executive Director, Home Care Program, The Joint Commission

Below are a few highlights and key points from the information packed hour:

  •  The Amedisys care transitions initiative decreased the average 12-month readmission rate from 17 percent to 12 percent.
  • The VCU Medical Center implemented a hospital-based transitional care program (TCP) 12 years ago that has served more than 500 patients.  This program resulted in a decreased use of hospital resources— including fewer inpatient days, shorter lengths of stay, and fewer intensive care unit days— after enrollment in the TCP.
  • A home-based care path following Total Knee Replacement reduces the patient’s hospital stay and lowers readmission rates.
  • The Heart Care at Home program helps patients avoid the “black hole” of returning home after hospital discharge with complicated medication regimes and restrictions through visits with home care nurses and the use of telehealth.
  • Palliative care and home health can work in tandem to reduce pain and manage symptoms while still pursing curative or life-prolonging treatments. Two programs- Kaiser Permanente’s In-Home Palliative Care Program and Sutter Health’s Advanced Illness Management (AIM) program have been successful in their efforts. The Kaiser program delivers all service into the home and contributed to increased patient satisfaction and an average cost savings of $8,000 per person and a 52% reduction in readmission rates heart failure patients.

If you missed the briefing, please visit to view the webcast and materials. We will also be bringing you a detailed blog post on each of the author’s articles in the coming weeks, so please be sure to check back here for updates!


How Accountable Care Organizations Are Thinking About Home Care

Guest Author, Rodney Hornbake, M.D.

I practice medicine in a quiet corner of Connecticut half way between New York and Boston.  But despite my location, I am in close proximity to two Accountable Care Organizations (ACOs).  There are now four in our state approved by CMS and in operation.  Several more are expected to be approved to begin operation January 1, 2013 and one of these will cover the entire state.  Elsewhere, physician organizations and hospital systems are beginning to act as if they were already accountable for the quality and value of the services they provide.

I have taken part in the planning for one of these ACOs, by leading the development and implementation of clinical strategies designed to make the ACO successful. The vehicle for the ACO is a large Independent Practice Association (IPA) known as Medical Professional Services (MPS).  The IPA includes more than 400 physicians in central Connecticut.   The purpose of this blog is to share the deliberations and planning as they relate to home care and to explore how others outside Connecticut are addressing the same issue.

During 2011, MPS explored multiple opportunities that were available as a result of the Affordable Care Act.  The CMS initiatives and health care delivery reform approaches that MPS considered were:

1. The Bundled Payments for Care Improvement Initiative;
2. Independence at Home; and
3. Accountable Care Organizations.

As part of our deliberations in regard to the Bundled Payments initiative, MPS convened a meeting with the leadership of five local home health organizations.  These included not for profit agencies, a hospital-owned agency and a for-profit agency.  In a short time, the group identified strategies to:

  1. Shift appropriate patients from facility based post-acute care to lower cost home based care;
  2. Improve operations of primary care practices to provide optimal support to home care;
  3. Improve operations of home care agencies to provide optimal support to primary care physicians; and
  4. Focus care on patient-centered goals.  This last strategy relates directly to the desire of many patients to avoid hospitalization and to focus instead on palliative care or hospice care.

These strategies in turn were accompanied by specific tactics.

  1. Share information.  This specifically means sharing discharge summaries and other key clinical documents with the home care agency.  (While the ACO anticipates health information exchange, a web portal or other high tech solutions, most agencies currently rely on faxes.)
  2. Support functional teams.  Every home care nurse would share his or her cell phone number with the physician who in turn would provide his or her cell phone number to the home care nurse.  Other providers will be added to the nurse-physician team as needed.
  3. Rapid cycle performance improvement.  MPS would host a weekly conference call to discuss every readmission from home care as well as every “near miss.”

In the end, MPS elected to become an Accountable Care Organization (CMS prohibits organizations from sharing in savings for more than one innovation project).  All the strategies and tactics developed to address bundled payments were adopted by the ACO when it began operation on July 1, 2012.

Other ACOs are also working to optimize post-acute care.  Detroit Medical Center includes eight acute care hospitals, multiple out-patient facilities and one post-acute care facility.  The health system has formed a virtual network of partnering post-acute providers and established a joint operating committee to oversee its operations.[1]  The focus is on improving clinical outcomes and efficiencies through collaboration on mutual goals.

HealthEast Care System in St. Paul, Minnesota is also relying on formalizing collaboration with selected post-acute providers to align the continuum of care to the maximum benefit of patients.[2]

Thus, while details vary from market to market, certain themes are emerging.  The most important one is collaboration among high performance organizations to achieve mutual goals.  Home health care organizations that understand this dynamic can strategically position their organizations in a rapidly evolving market place.

[1] Lauren Phillips, “Continuing Care Networks: Affiliating with Post-Acute Providers,” Health Care Financial Management Newsletter, (May 30, 2012), available online at–affiliating-with-post-acute-providers/.

[2] Ibid.