I recently watched a TED talks on health care and hospitals. The speaker was Niels van Namen who leads the global CEVA Healthcare team as the Executive Vice President for Healthcare in BD. Basically, the presentation covered what most of us in home health and home care already know, most acute care [estimated 57%] can be delivered in the home. It is where people want to be, and it is less expensive to have home health deliver the services. He echoed what we see every day and some of us on a personal level, it is difficult for people with disabilities to travel to the facilities to get treatment and to get to doctors’ offices for care.
For that to become a reality however, all of health care and especially home health will have to change the way they deliver services and how they train and educate the entire team of workers. We need to re-envision who we are and how we will meet the needs of our patients in a compassionate and cost-effective way. It will also require changes at CMS.
In order for comprehensive, effective care to be delivered in the home, there must be provision for the continuum. By that, I mean not only the acute and sub-acute care that we currently can do but there must also be a chronic care team that assumes responsibility for the patient and carries them indefinitely, perhaps for life.
In this world 80% of care would be delivered in the home with the remaining 20% would be critical care in the hospital. The reduction in expense could be in the billions if done right. The teams and practice are as follows”
Acute team: Emergency room and acute care nurses, ER or Hospitalist MDs, ancillary staff as needed and availability of mobile lab, X-ray and pharmacy.
Practice: The home health acute intake staff receive the call from either the ER or the MD office; one of the Acute teams is mobilized and go to the patients home while the patient is in route from the ER or the MD office. The patient is met at their home by the acute team. The Acute Physician follows up with the notes from the ER or MD office and does an assessment. Nursing carries out the orders and tends to any labs or other diagnostics that need to be done. The goal is to stabilize the patient so they can be passed off to the sub-acute team. If the course in the home follows the hospital at home demonstration grant, the patient should be ready in three days to transition to the Sub-acute team.
Sub-acute Team: [traditional home health modified to be what CMS originally expected home health to be] Physician from Acute Team, primary provider, RN Case Manager, PT, OT, Speech, MSW, and CNA; availability of mobile pharmacy, X-ray and labs.
Practice: Case is referred to team by Acute team [internal referral]; sub-acute team RN case Manager provides an OASIS assessment based on DC (discharge) summary from the acute team; all clinical staff determined to be on the care team must complete their assessment within the first three days; day 4 a shared care plan is complete and implemented; Admitting RN sees patient for the first three days and additional clinicians as needed. Patient has daily visits from at least one member of the team for the first two weeks/14 days. If patient is stable enough, the visit frequency drops to a maintenance level for two weeks. If determined stable at that point and independent patient is discharged. If the patient needs ongoing support and services and/or has a chronic condition the case may be referred/discharged to the chronic care team.
Chronic Care Team: RN Case Manager, Advanced CNA, MSW, Dietitian, Telehealth, Home Visiting Geriatrician MD or NP, availability of delivery pharmacy, mobile lab and X-ray. Home Modification repair team.
Practice: The chronic care team is responsible to keep the patient at home and as stable as possible. The focus is quality of life and immediate access to care as needed. The RN Case manager opens the case to chronic care with particular attention to the diseases affecting the patient. An Advanced CNA who is certified in the diseases affecting the patient will be assigned to assist with the patient with their ADLs and IADLs. The Aide will be assigned to shifts rather than visits. The frequency and duration of the shifts will depend on the identified needs of the patient. The patients primary care physician will assume responsibility for oversight and for ordering any clinical services. If the primary is no longer able to service the patient or the patient is homebound and it is too difficult to get out to see the physician, the Chronic Care MD will assume care and make home visits no less than every six months or as needed. the goal of this team is to never have a readmission to the hospital, unless it is for an elective surgery or something similar.
There have been numerous articles over the last few years about developing a continuum of care protocol, but so far not much progress has been made. To make this a reality, changes must happen in physician practices, home health and with CMS rules. Some day we may actually see this in action.