In-Home Care Management

Like so much of the health care system, home health agencies (HHAs) in the United States are at a crossroads. I might argue that HHAs face even greater challenges than our hospital or health care system counterparts face, as by definition, we represent the final point of connection with patients post-discharge. This appears to place the burden of reducing readmissions most squarely with us.

As it turns out, however, that is a burden we are uniquely prepared to shoulder; historically, home health is rooted in providing high quality care to patients in their homes and involving the patient in his or her own planning and execution of care.

These two aspects of our history allow HHAs to dovetail neatly into several key health care reform initiatives, summarized in what is known as the triple aim:

1. Increasing patient satisfaction. Most patients prefer to be cared for in the comfort of their own home.
    
2. Addressing population health goals. Our engagement with patients post-discharge puts us in the position of being able to provide broad-based educational initiatives, empowering patients to manage their own disease state.
    
3. Cost-effective means of delivering care. Moving care—especially for those patients who need ongoing care, as is the case with chronic illness populations—out of the expensive brick-and-mortar hospital walls lowers costs for patients, payers and health care systems.
    

As a result of these the triple aim goals, homecare is growing in relevance; many HHAs, once viewed as something of a care afterthought, are now being invited to key business strategy sessions within hospital networks and accountable care organizations (ACOs) as they map out a future that results in better patient care. New models of health care delivery are already starting to recognize the value of homecare in this context.

That said, key challenges must be addressed to realize the full potential of home health in facilitating achievement of triple aim initiatives.

Attaining high-value homecare will be critical to overcome silos created by fee-for-service Medicare, address aspects of the current home health benefit, and enable supports and infrastructure to allow patients to age in place.

To that end, home health providers can be high value partners in the care continuum, though our continued relevance in the space is best reflected by those progressive agencies who are looking to implement care solutions that blend traditional hands-on care with technology solutions that give us—and our patients—the capability to provide a long-term, scalable approach to care.

Reinventing Home Health

HHAs of the very near future need to prepare to embrace the challenges of a fast-changing landscape in order to remain relevant and keep up with the competition. Key among those challenges will be staying ahead of fast-changing technologies (and doing the work to implement them) as well as an increasingly complicated regulatory environment.

New Technology Solutions

Homecare providers have the opportunity to access and take advantage of the latest technologies in order to improve care while lowering costs. As the technology landscape continues to evolve, there are now a range of telehealth solutions that can transmit vital health data and other feedback between patients, loved ones, physicians and HHAs.

Significant research shows that patients who used remote patient monitoring (RPM) required fewer hospitalizations and lower medical costs compared with patients who did not have this technology at home. The reason for this is simple: if a home health nurse visits a patient one or two times per week, agencies get a limited snapshot of what patient vital signs (from weight to blood pressure to oxygen levels) represent.

While this limited snapshot is better than nothing, daily monitoring of vital signs has been shown to provide a much more complete picture of patient health. For example, if a patient with CHF gains three pounds in a single day, it can be an indicator of rapidly declining health.

If a patient with only in-home nurse visits experiences that type of weight gain the day after a visit, it might get missed until the next time the nurse visits the patient—by which time the decline in health could have been significant enough to warrant the patient going back to the hospital.

Daily monitoring highlights the change more quickly and allows for immediate courses of action to take place—such as a change in medication to address the weight gain—all of which can take place outside the hospital setting. Learning how to correctly and effectively use and these technologies takes considerable time and effort. Incorporating RPM technology will provide an unprecedented collaboration between all patient stakeholders, creating a seamless and personalized care plan.

The Visiting Nurses Association (VNA) recently piloted a program with a new RPM technology solution that allowed patients to monitor their own vital signs after the VNA had completed the reimbursable period of clinical oversight RPM. The key aspect of the solution they used was that it incorporates medical alert technology (or PERS) so that patients still have access to emergency assistance if they need it. The technology used (a system called MobileVitals by MobileHelp) provided a step-down solution to help patients transition from the clinical oversight we provide each day to managing their own care.

The results speak for themselves; pilot patients reported a 47 percent increase in confidence levels around managing their chronic condition and an 18 percent increase in mobility and physical activity. In addition, anecdotal evidence reveals even deeper measures of success. Several patients have identified their vital signs trending negatively—all on their own—and were able to reach out to their physicians to circumvent a hospital readmission.

Incorporating Education

One key aspect to addressing population health goals in the future, and providing better patient care post-discharge for all patients, will be in the integration of educational components.

The article, “Improving Health Outcomes With Better Patient Understanding and Education,” by Robert John Adams, explores the complex relationship between how “chronic disease self-management and preventive health programs…rely heavily on better information and communication practices around improved education and understanding of health behavior and chronic disease management.”

As HHAs are already a component of post-discharge patient interaction, they are well-positioned to provide educational tools to patients who are coming home with a chronic disease (or two or three) to manage. Here, too, is an area in which technology can step in to provide assistance.

At the VNA, a telehealth technology solution is currently in use with educational prompts for patients. In the long-term, in addition to their vital signs, these become markers and points for education to our patients of overall health. (i.e., it tells them with why legs become swollen or what the causes are for difficulty in breathing, as well as providing simple remedies to correct the issue.) Patients understand if they wake up to swollen feet or ankles, it is cause for pause,and potentially a call to their health care provider.

But what if it could be even more extensive? What if the telehealth platform used was able to provide patients with in-depth access to education about their disease state, specific care plans, or even games they could play to better understand their disease? New telehealth technology solutions that use tablet formats do just that.

HHAs that can bring a new level of education to their patients will better enable a key aspect to long-term positive changes in the health of their patient populations—empowerment.

Empowering Patients

While the health care industry may refer to empowered patients as “engaged,” I think there is a key difference: engaged patients want to be active participants in their health, but they may lack the education or tools to do so. Empowered patients are those who are given the right support, from in-person care to technology solutions, to manage their own disease—so their disease is not managing them.

As with educational resources, HHAs are ideally suited to provide patients with the tools and support systems they need to be empowered in the management of their own disease states.

Progressive HHAs are implementing new technology solutions, such as the integration of telemedicine to care for patients in novel ways, and deployment of preventive technologies that keep patients safe and out of the hospital. In addition, they are incorporating education and empowerment tactics to provide their patients with the ability to self-manage their own diseases, which positions them to manage challenging patient populations with chronic, co-morbid conditions.

These factors will allow HHAs to address the lion’s share of triple aim initiatives and assure them of a prominent place in the future of patient care.