Home Health: Proving Its Value
Published by Clinical Innovation and Technology
September 27, 2013
Home healthcare can fill care gaps, extend the reach of clinicians, improve clinical outcomes, reduce costs and more. The industry, however, must prove its worth to combat reimbursement challenges and the notion that home health cannot be a solid and consistent partner with other care providers. Health IT that drives care coordination and patient engagement should help build the case for home health.
"We strongly believe that technology is going to help us drive clinical improvement and also help us be more efficient,” says Paula Suter, director of clinical care management at Sutter Care at Home, based in Emeryville, Calif.
Suter cites the landmark Institute of Medicine report that highlighted care delivery gaps, namely that clinicians don’t have actionable information at the point of care. Sutter is working to fill that gap. The group also is focusing on clinical decision support because “I don’t think it’s realistic to expect clinicians to have all the current evidence-based guidelines in their heads at any given time,” says Suter. “We need to make it easy for them to provide the right care consistently, by making sure that decision support is embedded in our EMRs and is at the clinicians fingertips when they need it.”
Speaking of EMRs, Sutter is building a new tool into its IT system to improve the identification of patients at the greatest risk of future medical errors. The tool is designed to assess whether a medication regimen is too complex by evaluating patient behaviors in the home and physical and cognitive problems such as low vision and then automatically bringing over care plans tied to those identified problems.
In its effort to transform care, Sutter has expanded the role of inpatient liaison, a role that used to involve gathering data from charts which is eventually accessed by field clinicians. “Now, we’re trying to take a more holistic approach to care by having that in-hospital person function as a health coach,” Suter says. “They begin the assessment process looking for barriers while the patient is still in the hospital as well as identify any concerns they have about going home.” The liaison enters information into the EMR, such as lack of confidence in condition management, exhibiting symptoms of depression and health literacy level, so the field clinician knows at that first important visit which barriers to address. “It also helps determine which patients need to be seen within 24 hours of discharge by giving us an alert in the EMR that our schedulers review.”
Like Sutter, “technology is a big part of our clinical innovation and support of quality patient care,” says Patrick Thompson, executive vice president of operations and CIO of Amedisys, about his organization. Amedisys, a national home health provider based in Baton Rouge, La., currently is rebuilding incumbent technology and will go live in the fourth quarter. The upgrade includes more than 3,000 enhancements. “We’re taking technology and putting it on top of a new patient care management model as well as a new back office operations model of shared services.”
Getting care centers to collaborate effectively is part of the plan. Amedisys has care centers that are within 50 miles that currently work independent of each other. “In the future, we can have the care centers work more closely together by sharing information,” Thompson says. The company’s system upgrades will allow for collaboration, scheduling and clinical management between the centers. Clinicians can get dashboards and alert messaging so “everybody is informed about what is going on with their patients in a timely way.”
Of Amedisys’ 16,000 computers, 12,000 are in the field, Thompson says. Nurses and therapists, for example, take visit notes, perform medication reconciliation and record vitals for patients just coming out of the hospital. Those clinicians exchange information with physicians to get electronic orders. A physician portal provides instantaneous updates of field visits, so physicians can see the real-time status of their patients.
The company plans to extend its portals as a resource for patients and family members of patients, Thompson says. And, he sees greater use of telemedicine in the future. “Telemedicine allows for interoperability with things like Skype online videoconferencing. As those types of opportunities present themselves, we plan to leverage them to deliver more efficient care.”
Amedisys calls remote monitoring theory-based monitoring, says Thompson. “We don’t use it just to pick up exacerbations. We coach patients on how to report their signs and symptoms and provide positive reinforcement when patients are doing the right thing.” Looking to the future, the company plans to use the technology to manage limited resources. For example, with wound care nurses or certified diabetes educators, they are looking into using videoconferencing so clinicians can care for more patients.
“In the long run, telemedicine offers such a strong value proposition that it’s hard to imagine we’re not going to see some critical growth,” says Teresa L. Lee, JD, MPH, executive director of the Alliance for Home Health Quality and Innovation. Some 10,000 Baby Boomers are becoming Medicare beneficiaries every day and over the next 20 years, we’re going to see a huge influx in the number of frail elderly, she says. “We expect the number of patients over age 85 to triple. There’s no way that’s not going to lead to a strong demand for home-based services.”
Telemonitoring also has been successful for Eastern Maine HomeCare, based in Caribou, says Carol Carew, RN, chief nursing officer. It is particularly effective for patients at risk of readmission. “We use that technology to keep tabs on what’s going on with them. We look for trends to see if someone is creeping up into crisis, based on assessing key biometric indicators, and make an intervention plan. It has been really effective.”
For patients who have been to the emergency department twice within six months, the Community Care Team meets with them to find out why. One patient wanted to go to her primary care physician and would call 911 for an ambulance to take her, Carew says. Ambulance drivers, however, can only transport patients to the hospital. They got her cab vouchers to address the problem, cut her utilization and thus save money.
In this way, the care team helps patients navigate the healthcare system and “access the right points of care at the right time,” she says.
Interoperability for interventions
Interoperability also is a high priority for Eastern Maine. The organization is connected to HealthInfoNet, the state’s health information exchange, and relies on the service “to do a lot of the work for us,” Carew says. For example, if a HealthInfoNet-registered patient is hospitalized or visits an emergency department in the state, Eastern Maine receives an email flag. “That’s a great help to us because we spend a great deal of time tracking down patients.”
The organization also is working with a telestation that can be placed in the home to a landline or connected to a mobile device to push out tailored messages to patients to educate them and promote self-management.
Sutter is in the midst of a pilot project with a system hospital to reduce 30-day readmissions, focusing on heart failure patients, Suter says. “Our in-hospital liaison assesses patients for level of readmission risk, flags high-risk patients, which prompts the field clinician to conduct a very different type of visit—one that focuses on key transition interventions to prevent readmission. For example, more time is devoted on teaching signs and symptoms of exacerbation with an emphasis on who to call, using the “teach-back” method to ensure understanding and promote retention.
That initial visit triggers weekly and monthly reports to determine “whether we are meeting our targets for this high-risk group. We have established metrics for both quality and efficiency for care teams and for individuals. Each care team and each clinician will receive a report card and some of their incentives for performance will be based on whether they are meeting these metrics. In our transitions project, we review the reports weekly and create an action plan based on how we’re doing. We are using a systematic approach to drive care changes and incentivize our clinicians to do the right thing.”
Pushing patients to self-manage
Patient engagement can dramatically impact the success of home healthcare. Sutter Health wants to make sure its clinicians have the competencies to engage and empower patients, Suter says, and aid in smoother and more effective communication.
To that end, they are currently working with their EMR vendor to improve the medication list provided to patients. “Unfortunately, most lists are developed by clinicians and form language tends to be clinically focused. The terms are hard for patients to understand so we’re collaboratively redesigning the form with our EMR vendors so it’s truly patient friendly.” That includes simplified language and larger print. “We really believe that step one in patient engagement is making sure patients understand their situation and their treatments.”
“Our members are more interested than ever in trying to improve patient engagement,” says Lee. A big part has been encouraging the use of strong educational materials to teach self-management. “That’s a critical role for home healthcare.” The Alliance is working with patient groups to enhance patient engagement and will co-host a webinar this month on the subject. “Sometimes we do things that make sense from a clinical perspective but technology has a role in helping us make sure we’re capturing the patient’s perspective when trying to engage them.”
While technology can drive patient engagement, Eastern Maine has been working to ensure basic needs are met for their patients, says Carew. “Patients are not going to worry about their healthcare if they’re worried about their next meal.” Regular checks by nurse care coordinators ensure barriers are being addressed in a timely manner rather than waiting six months until the next office visit.
Telemonitoring has been an important part of this process, she says. “[Telemonitoring] gives people tools to see every day the differences they make in their choices.” If a heart failure patient, for example, has a big, salty meal, that probably will be reflected in his or her weight the next day. Even after a defined telemonitoring period, she says some patients continue to check their weight, blood pressure and other similar measures on their own. “That’s where we want to be with people really engaged.”
To keep improving communication and connectivity, “the standards and interoperability piece is really critical,” says Lee. This emerging area is important for the home health community “to be aware of and engaged in to make sure the right information will become the standard. If we’re not collecting the right data, we’re not able to effectively provide care, improve outcomes and improve quality of care. Having the right data points in place and standard is very, very important to exchange seamlessly with other providers and stakeholders.”
On a federal level, work is underway to develop a home health plan of care dataset, Lee says, and home health is leading the way. That dataset is “going to become the linchpin for all post-acute care information exchange.”
Until standards are set, many home health providers won’t want to make significant investments in health IT, says Lee. Before investing the kind of money required, “they need some level of certainty that they’re not wasting their money on systems that might become obsolete. Most providers we talk to are making investments because they have to. They’re shopping around among health IT vendors to try to make sure those companies are going to be able to adapt as standards are developed.”
The next frontier, Lee says, in home health and health IT is information exchange. “We have many providers beginning to be involved in state HIEs. We’re really trying to get to the point where there’s seamless HIE. It’s starting to emerge and it’s exciting.”
Home healthcare providers are increasingly thought of as partners, says Lee. “I absolutely think we’re increasingly being recognized in delivery reform.”
The great hope, she says, is that the right incentives are in place so the right technologies can be optimized to improve patient care.
Home healthcare providers are “looked to to help reduce hospital admissions and readmissions,” Lee says. Using technology is an essential part of the process, she adds. However, “we have our work cut out for us to identify best practices so that patients, home health providers and physicians are really able to optimize the technology.”
CMS is piloting projects focusing on high-risk patients, says Thompson. “As a result, there’s going to be a hyper-focus on the 5 percent of the Medicare population that’s eating up 49 percent of healthcare costs. Hospitals and providers are seeing that home health is a solution to this problem. Home healthcare is a way of reducing costs and taking care of patients where they belong.”
Carew says her organization is in a crunch “with all the cuts we face.” Eastern Maine wants to expand its mobile home monitoring system and provide services to accountable care patients who don’t meet traditional Medicare criteria. But, “we have one foot in the old world and one in the new until we really, truly go under a pay-per-member-per-month rate and have some freedom and flexibility in how we care for our patients.”
Home healthcare has the onus to ensure other providers understand “the comprehensive nature of the services we provide,” says Suter, and turn to home health as experts in self-management support. “We have more education and work to do to demonstrate what we can do. We have to be so good that [other providers] can’t ignore us.”