Chronic Disease Management

Hospitals and Home Health Collaborate

The impending changes in healthcare will require that providers in all facets of health care focus on ways to improve their practices. In 2012, hospitals will be facing a major change in the payment system called Pay For Performance (P4P). Under the new system, hospitals will be penalized by receiving reduced payments for performance below the national standard, as well as rewarded for performance that meets, or is better than the national standards. Similarly, home health agencies will receive payment for their services under the new P4P system. The goal of the new payment system will be to reduce the number of hospital re-admissions that are considered to be avoidable. Therefore, P4P assigns accountability to providers for hospital re-admission of their patients. It proposes that there are numerous factors that are modifiable such as incomplete medical workups during hospitalization, lack of understanding of discharge instructions, lack of adequate assistance in the home, or insufficient patient teaching during hospitalization. All of these factors directly affect the transition from the hospital to home and contribute to patient safety. Hospitals will look to home health agencies as key partners in transitioning patients, since their ability to prevent hospital re-admission will be a reflection on the hospital as well.

Chronic disease management will be integral in preventing hospital admissions, since patients with chronic diseases are likely to be hospitalized more frequently. The principal diagnoses that have been identified are congestive heart failure (CHF), diabetes, chronic obstructive pulmonary disease (COPD), stroke, and cancer. The goals of disease management are to: reduce signs and symptoms, decrease mortality, as well as prevent exacerbation, and the progression of these chronic diseases. Hospital case-managers and home health agencies will work closer than ever before to close the gaps, so to speak. Together, we will assess patients’ needs and identify those who are considered “ high risk” for hospital re-admission. Red flags will be identified , such as patients with recent prior hospitalization, prior emergency room use, those with limited help at home, confused patients, and patients with multiple medical diagnoses. Additionally, patients who are at risk for falls will be included in this high risk group. This system of risk stratification will assist providers in tightening up current practices. For example, an agency might provide more frequent visits immediately following discharge from the hospital, and keep the patient under service for a longer time period, in order to ascertain patient readiness prior to discharge from home health services. Similarly, hospital nurses may make follow up calls to patients to be sure that they are recovering safely, and that home health needs are being met.

One clear advantage of these upcoming changes in our health care system is that all providers will be inspired to be resourceful and assume accountability for their performance, which should improve patient outcomes. There is of course one necessary element , which has not yet been mentioned. Patient compliance is just as important in achieving better outcomes. On the other hand, health care providers will also be held responsible for factors that may be beyond their control, such as disease progression , despite modern medicine. Telehealth will have a definitive role in safely transitioning patients. Telehealth is a system of monitoring home health patients with a device that is capable of measuring vital signs, weight, heart rate, pulse oximetry (a measurement of oxygen in the blood), etc. The data is sent to a central monitoring station within the agency. The home telemonitoring system is especially useful for patients who need to be closely monitored in between nursing visits. Patients with congestive heart failure, coronary artery disease, high blood pressure, asthma, and COPD may especially benefit from telehealth.

The use of clinical pathways will assist home health agencies and hospitals in standardizing care. They will also allow for length of stay parameters that also synchronize care within the interdisciplinary team. Additionally, they will serve as tools in measuring outcomes against standardization. Patient education will be vital in accomplishing the established goals. Written material will need to not only be informative, but it must all be written in plain English and not in medical terms to facilitate patient comprehension. Hospitals and home health agencies will employ nurses with specialized training such as Cardiac Nurses, Certified Diabetes Educators, Certified Wound Care Nurses, as well as Advanced Practice Nurses to provide expertise disease specific education.

Mihom Healthcare, on their part has focused on honing their standard for care on its CHF patients. This diagnosis affects over 5.5 million predominantly elderly individuals, and it is the underlying cause for 12-15 million office visits and 6.5 million hospital days per year. Therefore, CHF ranks as a top primary & secondary diagnosis in individuals of the 65 and up age group. CMS refers to this phenomenon as a ‘revolving door process’ leading to cyclic re-admissions. Accordingly, Mihom Healthcare has initiated its evidence-based interventions: clinical pathways for CHF, including the use of Telehealth and follow up phone assessments. These tools have been proven to reduce re- hospitalizations of CHF patients. Mihom Healthcare embraces the opportunity to efficiently improve its care delivery outcomes, while partnering with hospitals and physicians, as we embark upon these changes. Telehealth is also offered on a private pay basis, as are other private care services.