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.

Celebrating Older Americans Month: Utilizing Home Health Care to “Unleash the Power of Age”

This month is Older Americans Month, a joint recognition month sponsored by the U.S. Department of Health and Human Services’ Administration for Community Living and Administration on Aging. The 2013 theme, “Unleash the Power of Age!”, celebrates the contributions of older Americans in this country. Some of the month’s activities include a “challenge” for adults age 60 and older to demonstrate how they continue to be actively engaged in their communities (for more information, please visit

After receiving treatment for an injury or illness, many older Americans face the challenge of becoming active again. A look at the Home Health Chartbook identifies some characteristics of older adults using home health services:

  • Following an inpatient stay, 38.7 percent of Medicare beneficiaries are discharged to post-acute care.
  • Major joint replacement or reattachment of lower extremity without a major complication or comorbidity accounts for the largest percentage of Home Health Part A claims in 2010 at 10.77 percent, or 211,779 claims that year. Another 31,145 claims were made for hip and femur procedures with a complication or comorbidity.
  • Medicare home health users with the most common diagnoses experienced slightly lower 30-day rehospitalization rates than skilled nursing facility users, including a mere 4.33 percent rate among major joint replacement or reattachment patients.

Home health is a vital post-acute tool for patients, especially older Americans, looking to safely recover from injury or illness while continuing to work toward a healthy and productive future. One rapidly growing treatment in particular – total knee replacement (TKR) procedures- are critical for older Americans who wish to remain active and involved in their community. A recent article from the Cleveland Clinic Journal of Medicine’s electronic supplement, “Optimizing Home Health Care: Enhanced Value and Improved Outcomes” focuses on the ways home health can benefit TKR patients.

In an effort to address patient concerns over the length of expected recovery from TKR, a Rapid Recovery Care Path was developed which emphasizes discharging patients back into their homes as soon as it appears safe to do so. Since the program’s implementation in 2006, the program has shown several positive results, including lower readmission rates for patients discharged to home as compared to rates before the protocol was implemented, and a cost savings to the system of about one-third compared to patients discharged to an inpatient post-acute facility. (The full article on TKR can be found here.) Better outcomes at decreased costs will help older Americans stay active members of the community, continuing to improve the lives of others.

Additionally, older patients have found they prefer to recover at home as described in an April 2013 study in the International Journal of Nursing. In the study, early assisted discharge patients (those who were discharged on day four and received visits from a home care nurse until day seven) managing from Chronic Obstructive Pulmonary Disease preferred to receive care in the home. (To read an abstract of the article, click here.) Similarly, a 2011 study published in Telemed and E-Health shows high-levels of patient and healthcare professional satisfaction using in-home telerehabilitaion. (To read an abstract of the article, click here.)  These studies confirm that in general, older adults prefer to recover from illness in settings that allow for more independence—specifically the home.

We at the Alliance, as part of the home health care community, congratulate and thank older Americans for their positive contributions to society, and encourage the continued support of our older population. In order to best care for, and thus benefit further from, the older American population we must be steadfast in our commitment to providing high quality health care.  Home health lets older Americans in need continue to contribute to society from a safe and comfortable setting while they are treated.  Appropriate use of home health enables a very capable and important population to unleash the power of age.