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News Roundup: January 22, 2016

Home Health Beats Inpatient Care on Outcomes, Cost

Published by Home Health Care News
By Amy Baxter
January 22, 2016

Referring patients to home health care could yield better results than inpatient care, according to a study recently published in the journal Medical Care. The study is part of an ongoing effort to reduce costs across the health care system, and the latest findings spell good news for the home health industry.

With the cost of post-acute care services reaching $62 billion annually, what happens to a patient after leaving the hospital is crucial and increasingly coming under scrutiny. Post-acute care is the largest driver of overall variation in Medicare spending, the study noted, citing a report from the Institute of Medicine.

“Post-acute care is receiving increased attention from policymakers for a variety of reasons,” the study reads. “…Growth in spending for post-acute care is also accelerating faster than that of other health care services, causing some to suggest that post-acute care represents the next frontier for controlling Medicare costs.”

Currently, hospitals set the tone for how a patient will receive care after being discharged, whether through inpatient services at another facility or through home health care services.

The study noted there is little oversight for how hospitals make their decisions for a care plan, with huge discrepancies across the country for where patients are referred. For example, the study found that some hospitals refer less than 3% of patients to inpatient facilities, while others are closer to 40%.

The study also found that patients who were referred to home health care plans had better health outcomes. Hospitals that referred patients to inpatient facilities tended to have shorter lengths of stay and higher readmission rates, according to the findings.

“These findings suggest that some hospitals may be using post-acute care as a substitute for inpatient care,” Dr. Greg Sacks, the study’s lead investigator, a resident in general surgery resident at UCLA and a Robert Wood Johnson/Veterans Affairs Clinical Scholar, wrote in the study. “This might lead to patients being discharged from the hospital prematurely, which then results in higher readmission rates.”

However, study authors noted the reasons for early discharge and the association with inpatient post-acute care needed further study to explain the results.

As the Centers for Medicare & Medicaid Services (CMS) and Congressional members consider new incentive initiatives to reduce costs, better health outcomes from home health patients could potentially lead to more coverage for these types of services and agencies. CMS has already taken steps to incentivize post-acute care planning in low-cost settings with bundled payments and encouraging coordinated care.

The first step is creating effective discharge guidelines for post-acute care planning, as the study argues that a lack of guidelines will continue to create variation in care costs.

Family Caregiving Isn't Easy: Emotional Management Tips

Published by Huffington Post
Steve Landers MD,MPH
January 22, 2016

Co-Authored With Michael Brustein PsyD. Dr. Brustein (@DrBrusteinNYC) is a clinical psychologist in private practice in New York City. He is the author of Perfectionism: A Guide for Mental Health Professionals

Are you part of the essential, but often overlooked, workforce of unpaid caregivers? Juggling work and other family and personal roles while helping care for someone? You're not alone. Over 65 million Americans are caregivers for loved ones needing help due to illness, disabilities, or aging.

Just hearing the phone ring or a text message ping can trigger caregiver anxiety. Has mom fallen? Is the news bad? Should you cancel plans to be by their side? Balancing caregiving with professional, parent or partner roles may be overwhelming. It's normal to feel conflicted, and mixed emotions such as love and loyalty, resentment and anger may occur simultaneously.

If you're already experiencing emotional struggles and feeling distressed, you should promptly seek help from a primary care or mental health professional. If things are generally going well and you want to prevent or reduce the impact of potential emotional challenges, here are some tips for coping:

1. Anxiety: It's common when facing unfamiliar medical issues such as upsetting symptoms and complex treatments and technologies. You may not know how to help or even fear that you'll make things worse. Additionally, seeing loved ones in decline can be very jarring. These images can bring up distressing thoughts about your own life and death, and you may realize more deeply that life is finite. These feelings can be very unpleasant and a desire to avoid contact and caregiving responsibilities may arise.

Tips: Anxiety about unfamiliar situations may be lessened if you feel confident and informed. Organizations such as the Alzheimer's Association, National Parkinson Foundation, American Heart Association, and the American Cancer Society have resources for caregivers.

The anxiety about death that arises in the caregiver role can be used in a positive fashion; accepting the boundaries of time can motivate sharing of thoughts and feelings you may have never addressed with your loved ones. You may be able to better focus on what really matters.

2. Guilt: As caregiver to a parent there is often a concern about whether you're doing enough. The desire to be the good son or daughter lives on. To undo guilt you may compensate by doing more than you are capable of leading to anger or resentment.

Tips: Don't forget that most parents want their children to be happy, engage in self-care, and not be overwhelmed. Although aging parents with serious illness may not be able to communicate this directly, think back to times when they were nurturing and concerned.

Additionally, self-acceptance is important. You may wish to do more, but everyone has limits. Respecting and understanding limits does not make you a bad person. Rather, self-acceptance can prevent burnout and keep you more engaged and present.

Make sure you're aware of all available help from local visiting nurse, home health, aging, and long-term care organizations. Even if you can't always be there yourself, you'll feel better knowing that caring professionals are involved.

3. Grief: Although still alive, you may find yourself grieving the person you once knew. This is especially common in advanced cases of dementia as you witness a once highly functioning person now struggle to recall names and repeat basic questions. Progressive decline caused by certain diseases can be very painful if each time you face them it feels as though you are experiencing losses over again.

Tips: Mourn the person who is no more, but engage with the person who is. Appreciate that they still can have pleasant moments. For instance, many individuals with dementia have some distant memory intact. Reviewing old pictures and seeing them smile can be an extremely valuable interaction. Story telling, prayer, listening to music or enjoying the aromatic flavor of a candle can also create connecting and meaningful moments.

4. Anger: When witnessing the decline of a loved one, anger about how unfair it is to see them struggling is not uncommon. You may also be angry that they many not be able to see and experience future things in your life such as children going to college or other milestones.

Tips: Having gratitude for the time you had with your loved one can be helpful. Reflect on the joyous times they had, honor the life they lived and what they accomplished personally and professionally. Remember that to some extent they live on in others they have influenced. Make sure that their doctors and other health care providers are respecting previously stated wishes or advance directives. Enlist the help of hospice and palliative care programs to ensure comfort and dignity when there's not likely to be a cure.

None of these tips should be used as a substitute for the individualized advice and help of a physician or psychologist. If you are having real difficulty with emotional management, seek professional help immediately.

This post is part of Common Grief, a Healthy Living editorial initiative. Grief is an inevitable part of life, but that doesn't make navigating it any easier. The deep sorrow that accompanies the death of a loved one, the end of a marriage or even moving far away from home, is real. But while grief is universal, we all grieve differently. So we started Common Grief to help learn from each other. Let's talk about living with loss. If you have a story you'd like to share, email us at strongertogether@huffingtonpost.com.

House calls program for ailing seniors saves health care dollars, study finds

Published by USC News
By Emily Gersema
January 22, 2016

A Los Angeles program that makes house calls to older patients shows promise as a national model for other health care companies to save money, USC researchers say.

The Affordable Care Act in 2010 offered incentives for companies to pilot programs that would save the system money, including home-centered programs to assist seniors with high-risk health conditions. HealthCare Partners Affiliates Medical Group launched House Calls in 2009 to serve Los Angeles area patients — making it one of the first and oldest such home-centered programs in the country.

In a new study published this month in the journal Health Affairs, USC Schaeffer Center for Health Policy and Economics and USC Price School of Public Policy researchers found that the House Calls program became more efficient as it reduced health care spending and hospitalization rates over the course of a few years. The patients were considered “high risk” — older and with multiple co-morbidities. A few of those include diabetes, hypertension, congestive heart failure, renal failure and cardiac arrhythmia.

The study was funded by the California HealthCare Foundation.

“Overall, we see a potential for substantial improved patient outcomes and potential savings in total health care costs from this home-based care program for high-risk Medicare beneficiaries,” said lead author Glenn Melnick, professor at the USC Price School and the USC Schaeffer Center.

According to data provided by House Calls to the researchers, the average monthly program cost for enrolling a patient in the House Calls program declined over time to less than $200 per patient — from a range of $187-$310 in 2010 to $147-$185 per patient per month in 2013.

Hospitalization rates drop
Researchers also found that hospitalization rates dropped from 159 per 1,000 patients in the six-month period before patients were enrolled in House Calls to 96 admissions per 1,000 patients during their enrollment in the program. Within the six-month period after patients left the program, House Calls program admissions stabilized at 100 admissions per 1,000 patients.

The program evolved over time and gradually used fewer physicians for services while increasing its reliance on nurse practitioners. This money-saving move reduced the company’s salary overhead for physicians from 45 percent in 2010 to 24 percent in 2013.

“House Calls achieved savings primarily through better monitoring of high-risk patients and then by coordinating their care with multiple health professionals, which is complicated since these patients tend to have multiple conditions,” Melnick said. “Monitoring and coordination keeps them out of the emergency room and hospitals as inpatients.”

Melnick said the study did not assess costs incurred by family members or friends who serve as caregivers for these patients when they are at home. Researchers are investigating those undocumented costs for a later study, he said.

Home Care for Seniors: a Win-Win

Published by US News Health
By Lisa Esposito
January 22, 2016

What's not to like? Older adults with disabling conditions get easier access to medical care. Doctors get out of their stuffy offices to make new-age house calls. Nurses hit the road and see what patients really need. Medicare gets the promise of reduced hospital readmissions. Family members get more peace of mind. And most important, seniors get a chance to stay in their homes as long as possible. Home health care in the U.S. comes in many forms. Here are just a few:

Home Field Advantage

With today's portable medical technology, physicians who make home visits can do as much or more for patients than primary care clinicians in offices, says Dr. Alan Kronhaus, co-founder and CEO of Doctors Making Housecalls, based in Durham, North Carolina.

His practice uses medical labs that can deploy a phlebotomist to a patient's home to draw blood and send the results electronically to the patient's chart. Imaging technicians can do ultrasounds or X-rays in the comfort of the patient's home.

These aren't everyday patients who get home visits. "For the most part, we're seeing frail, elderly, complex patients with multiple, chronic, active problems and often some degree of cognitive impairment," Kronhaus says.

Many clinical advantages come from seeing patients in their own environment, Kronhaus says, like the ability to manage medications more effectively when the doctor can see exactly what's inside the medicine cabinet. It's also a chance to spot nutritional supplements that patients wouldn't have thought to mention during an office visit.

And it's an opportunity to address diet concerns, Kronhaus adds. "You can look into the refrigerator and see how it's stocked – if you've got a diabetic patient who has banana cream pie." Doctors evaluate the environment as well, he says. "We look for things like steep steps without carpeting, area rugs without nonskid padding underneath, electrical cords that could represent a tripping hazard, poor lighting."

To compensate for the "opportunity costs" of the doctor's transit time, patients pay a direct travel fee of $95 per visit. But, Kronhaus says, other costs are avoided, such as paid time off at work taken by family members to escort patients to the doctor's office, the round-trip cost of a wheelchair-enabled van or, in the worst-case scenario, the cost of transport by ambulance.

Doctors Making Housecalls is participating in Independence at Home, a Medicare shared-savings demonstration project involving a handful of home-based primary health providers throughout the country. The project has been "an unabashed success," Kronhaus says. "We've achieved dramatic savings and very significant improvements in quality of care and patient satisfaction."

Piecing It Together

Home health agencies fill a gaping need, but with economic and reimbursement pressures, many are struggling to survive, says Jane Kelly, executive director of the Kansas Home Care Association, a nonprofit trade organization. "There are four agencies out in western Kansas that are trying to serve literally hundreds and hundreds of miles of rural farmlands," she says. "And people can't get services because the agencies can't stay afloat."

With home health care, insurance coverage is often a hurdle. Patients who are not housebound may not be covered, even though getting to medical appointments can be physically challenging and transportation difficult to arrange. There's a high bar for reimbursement, and once a patient shows some improvement, he or she may no longer qualify for home visits. Yet access to skilled nursing, physical therapy and other services at home can prevent costly hospital readmissions and help patients avoid expensive long-term facilities, Kelly says. "Most people want to stay at home as long as they can," she says.

Family members do their best to support ailing parents by assembling a patchwork of skilled and personal services – such as help with toileting, bathing and dressing – through limited insurance coverage and government funding, or by paying out of pocket. "The options are, you piece it together," Kelly says.

On the Road

There's a lot of "windshield time" for nurses providing home care in isolated rural areas, says Terri Wahle, a registered nurse and director of home care at Geary Community Hospital in Junction City, Kansas. Wahle's team works with retired farmers and many other patients with often limited means.

For the nurses, Wahle says, a 10-hour workday may include three hours spent on the road, meaning less time to provide much-needed care for chronic conditions such as diabetes, heart failure and chronic obstructive pulmonary disease. Some homebound patients have several conditions.

After a hospital stay, supports at home may be lacking, Wahle says, even though patients' discharge plans say otherwise. "Do they have a bathroom they can get into with the walker?" she asks. "Are they able to fix themselves a meal? Are they able to get any food at all? Are they taking their medications?" These are some of the signs home health nurses look for.

Without regular access to home health care, some elderly or disabled patients can soon find themselves back in the hospital. "One of the things I've taken pride in for the last 30 years in home care is that we try to keep people in their own home for as long as it's safe and it's possible," Wahle says.

Quality Time at Home

When doctors or nurse practitioners go to patients' homes to make a thorough geriatric assessment, as part of a Medicare home-visit program, everybody wins, according to a recent study. The system saves money from lower hospital admission rates, and patients are less likely to enter long-term care facilities. With referrals to community providers and health plan resources, these patients tend to receive more follow-up care in the community and have a better chance of aging in place.

One problem with traditional health care, in which patients are only seen on providers' turf, is that health issues are dealt with in isolation, says study author Dr. Soeren Mattke, a senior scientist at RAND Corporation, a nonprofit research organization.

"When they go to the physician, they have maybe 10 minutes' face time," Mattke says. "So what often happens is the conversation focuses on what is the most pressing issue that day. But many other things that also have to be handled really never get any attention." Lingering problems from multiple conditions, while not immediately threatening, can worsen and accumulate, he says.

Comprehensive home assessments help uncover clues to frail seniors' health, Mattke says. Nutritional issues can emerge, for instance, like patients subsisting solely on canned beans. Like others, he remarks on the quantities of expired or discontinued medications patients typically have at home. "After a while, they really don't know what's what anymore," he says. Invariably, he says, it's the most essential medications that patients stop taking first.

Safe Respite and Handy Help

Adult day programs provide respite for family home caregivers so they can return to their responsibilities with energy and spirits restored. "Ninety percent of the people who call us, [it's because] they don't want to put their husband or wife or their mom or their dad in a nursing home or a long-term care facility," says Darlene Turner, director of the West Valley life enrichment program at Benevilla, a provider of adult social care and support services based in Surprise, Arizona.

The situation might be that the husband has dementia and the wife needs a short break. "She would maybe like to go do groceries without having to worry about him, or maybe go get her hair done," Turner says. "Or go have lunch with her friends."

For seniors who attend, these programs improve quality of life, Turner says: "Once they get here, everyone is given an opportunity to have an enriching day, to do things they wouldn't usually do if they were left alone at home." The daily fee for an independent senior is $75, and it's $80 for an individual who requires some staff assistance, Turner says.

Other services, like home-delivered meals, benefit older adults living alone in the community. Volunteers with Benevilla provide handyman services when needed: changing lightbulbs, replacing air conditioner filters, fixing leaky faucets. "We're actually able to send volunteers to their homes to bring their groceries, to pick them up and take them to doctors' appointments; maybe pick up prescriptions," Turner says. "And that way, they're able to stay in their own environment."