Post-acute care shift­ing to com­mu­nity set­tings

‘Heavy-lift­ing’ will shift to com­mu­nity-based care

Modern Healthcare - - NEWS - Steve Nahm and Ge­orge Mack Steve Nahm, left, is se­nior vice pres­i­dent at Com­pan­ion Man­age­ment Group, Santa Ana, Calif, which man­ages Outreach Care Net­work and also pro­vides con­sult­ing ser­vices to CareRx. Ge­orge Mack is vice pres­i­dent of payer and provider

READ More com­men­taries at mod­ern­health­care.com/com­men­taries

Health­care providers know that one of the prin­ci­pal chal­lenges fac­ing our so­ci­ety is car­ing for the vast num­ber of ag­ing Amer­i­cans re­quir­ing health­care. More than 10,000 peo­ple a day reach Medi­care age, some of whom will de­velop mul­ti­ple chronic con­di­tions and ac­count for a large share of Medi­care spend­ing. The strain will fi­nan­cially over­whelm an un­changed health­care de­liv­ery sys­tem.

In re­sponse, many health­care providers are re-en­gi­neer­ing their path­ways of care to pro­mote al­ter­na­tives to re­peated hos­pi­tal­iza­tions. Th­ese al­ter­na­tives—fill­ing in what some have called the frag­mented “chasm of care” in post-acute set­tings—in­clude greater use of pal­lia­tive-care spe­cial­ists, ge­ri­atric nurse prac­ti­tion­ers, ex­panded roles for phar­ma­cists and so­cial work­ers and pa­tient nav­i­ga­tors in pa­tient- and fam­ily-cen­tered home­based and com­mu­nity pro­grams.

In short, “post-acute care” has be­come an anachro­nism. In the fu­ture, a greater por­tion of the heavy-lift­ing of health­care will be per­formed in many non­hos­pi­tal set­tings, posta­cute and be­yond. Be­cause of that shift, we call it com­mu­nity-based care.

Hos­pi­tals can no longer live in a four-walls, brick-and-mor­tar world. Com­mu­nity-based care will be the fu­ture met­ric against which providers will be mea­sured. That is, their re­im­burse­ment will be based on per­for­mance of care ren­dered in mul­ti­ple provider sites by var­i­ous types of care­givers, in­clud­ing in-home set­tings.

Many ser­vices are al­ready more ap­pro­pri­ately and af­ford­ably per­formed in the home. The trend is be­ing en­cour­aged by telemedicine and new bio­genetic de­vices. In­deed, with in­creased elec­tronic con­nec­tiv­ity, we will be able to re­duce over time much of to­day’s un­nec­es­sary pro­ce­dures and acute-care stays, er­ror-prone med­i­ca­tion or­der­ing prac­tices and pa­tient non­com­pli­ance.

More ser­vices must move out to set­tings where both pa­tient and fam­ily mem­bers can be en­listed to treat and pre­vent ill­ness and ser­vices are typ­i­cally less ex­pen­sive. Health­care providers can­not al­ter be­hav­ior with­out the ac­tive par­tic­i­pa­tion of pa­tients and their fam­i­lies. Com­mu­nity-based care pro­grams are demon­strat­ing that par­tic­i­pa­tion is best achieved in the res­i­den­tial set­ting. In the home, pa­tients and fam­ily mem­bers are more re­laxed and able to re­mem­ber what they are taught.

Hos­pi­tals can no longer live in a four-walls, brick-and-mor­tar world.

While there are ex­cep­tions, the home is the pre­ferred set­ting to dis­cuss disease man­age­ment, preven­tion coun­sel­ing, life­style changes and end-of-life care. Send­ing providers to the home also en­ables a so­cial as­sess­ment of the en­vi­ron­ment and eval­u­a­tion for re­fer­ral of other ser­vices such as cus­to­dial sup­port.

Two rel­a­tively new ser­vices in South­ern Cal­i­for­nia are show­ing pos­i­tive re­sults us­ing a com­mu­nity-based ap­proach. One is the Outreach Care Net­work in Pasadena. OCN started as an out­pa­tient pal­lia­tive-care ser­vice but has evolved to serve pa­tients with mul­ti­ple chronic or life-lim­it­ing ill­nesses, most of whom have had mul­ti­ple trips to the emer­gency de­part­ment or numer­ous hos­pi­tal­iza­tions.

Through hands-on as­sess­ments, nurs­ing sup­port, co­or­di­na­tion of care, rapid in­ter­ven­tions and the pal­lia­tive con­trol of pain and symp­toms, OCN has re­duced avoid­able ad­mis­sions and ED vis­its. In the home set­ting, OCN care­givers are able to give fo­cused ed­u­ca­tion and, when ap­pro­pri­ate, have del­i­cate dis­cus­sions re­gard­ing prog­noses and end-oflife op­tions.

The sec­ond pro­gram, of­fered by hospice phar­macy ad­vi­sory com­pany CareRx, sends a phar­ma­cist into the home set­ting for face-to­face meet­ings with pa­tients and fam­ily mem­bers. A typ­i­cal pa­tient has mul­ti­ple chronic and pro­gres­sive dis­eases, nine-plus med­i­ca­tions, two or more pre­scrib­ing physi­cians, med­i­ca­tion ad­her­ence prob­lems and is likely to be non­com­pli­ant with the med­i­ca­tion reg­i­men. Stud­ies in­di­cate that up to 35% of hospi­tal read­mis­sions are caused by some type of med­i­ca­tion-re­lated prob­lem. Con­sul­ta­tion re­fer­rals come from case man­agers, hospi­tal- ists, pal­lia­tive-care physi­cians and in­creas­ingly from pri­mary-care physi­cians.

In many sit­u­a­tions, home-vis­it­ing phar­ma­cists im­prove care tran­si­tions by con­duct­ing med­i­ca­tion rec­on­cil­i­a­tions at home rather than in the hospi­tal. Un­like nurses and other types of clin­i­cians, phar­ma­cists are viewed as ex­perts on med­i­ca­tions, and pa­tients tend to openly com­mu­ni­cate with them, es­pe­cially in the home set­ting. Also, they can ac­tu­ally see pa­tients’ med­i­ca­tions and dosage in­for­ma­tion, which pa­tients of­ten fail to re­call or men­tion while in the hospi­tal.

As a re­sult, phar­ma­cists can de­velop com­pre­hen­sive med­i­ca­tion plans and con­vey the rel­e­vant in­for­ma­tion. Phar­ma­cists have found and re­solved du­plica­tive med­i­ca­tions, un­rec­og­nized side ef­fects, self- or past clin­i­cally pre­scribed med­i­ca­tions not rel­e­vant to cur­rent con­di­tions, mis­un­der­stand­ings of the pre­scrip­tions and other lim­i­ta­tions to med­i­ca­tion com­pli­ance.

With home-vis­it­ing phar­ma­cists as part of the care team of case man­agers, other care­givers and pri­mary-care physi­cians, CareRx’s re­sults to date have been im­pres­sive. The 30day read­mis­sion rate is less than 2%, and the 90-day read­mis­sion rate is 23% ver­sus more than 34% na­tion­ally for all Medi­care pa­tients.

As hos­pi­tals and their physi­cian part­ners move to de­velop ac­count­able care or­ga­ni­za­tions, th­ese provider net­works will need to demon­strate that their evolv­ing sys­tems are con­nect­ing the dots. They can best do that by cre­at­ing or­ga­ni­za­tions ca­pa­ble of de­liv­er­ing the com­pas­sion­ate care our pa­tients de­serve in com­mu­nity set­tings.

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