Health­care at home

Doc­tor, home-care part­ner­ship en­sures su­pe­rior post-acute clin­i­cal ser­vice

Modern Healthcare - - OPINIONS / COMMENTARY - Dr. Michael Flem­ing Michael Flem­ing is for­mer pres­i­dent of the Amer­i­can Acad­emy of Fam­ily Physi­cians and chief med­i­cal of­fi­cer of Amedisys Home Health and Hospice Care.

For a long time, many of us health­care pro­fes­sion­als have op­er­ated largely within our own com­fort zones. We do just as we’ve al­ways done, act­ing in­de­pen­dently of each other, as if in our own pri­vate uni­verse. We saw lit­tle in­cen­tive to change, least of all soon.

That’s hap­pen­ing less of­ten now, thanks mostly to pres­sures for health­care re­form from the fed­eral govern­ment and pri­vate sec­tor alike. But our ap­proach to car­ing for pa­tients re­mains frag­mented. We’re still go­ing to have to break free of those com­fort zones.

If we have agreed on any­thing in re­cent years, it’s that the health­care sys­tem should be bet­ter co­or­di­nated. Un­der the cur­rent sys­tem, physi­cians who should con­sult with each other about pa­tients do so only oc­ca­sion­ally. Too many un­nec­es­sary tests are still per­formed and too few pre­scrip­tion reg­i­mens fol­lowed.

Nowhere is this dis­jointed for­mat more ev­i­dent than in the re­la­tion­ship be­tween the health­care pro­fes­sion as a whole and or­ga­ni­za­tions that spe­cial­ize in de­liv­er­ing health­care at home. That’s a shame, given in­creas­ing ev­i­dence that with our pop­u­la­tion liv­ing longer, of­ten with chronic ill­nesses, a grow­ing seg­ment of pa­tients may be bet­ter served at home than in in­sti­tu­tions.

Our pop­u­la­tion, it turns out, has moved ahead of our health­care in­fra­struc­ture. As a re­sult, vast needs are go­ing un­met. Some pa­tients are go­ing with­out health­care at home, de­priv­ing them of es­sen­tial ther­a­peu­tic ser­vices to im­prove ba­sic func­tions we all take for granted.

For decades, no­body in health­care re­ally had to talk all that much to any­one else; that held true for dia­logue be­tween hos­pi­tals and home health agen­cies. In­deed, a 2006 sur­vey by Press Ganey, “Pa­tient Sat­is­fac­tion and the Dis­charge Process: Ev­i­dence-Based Best Prac­tices,” found that more than 80% of pa­tients who re­quired help with ba­sic func­tional needs never re­ceived a home health­care re­fer­ral. For that mat­ter, a 2009 anal­y­sis of Medi­care re­hos­pi­tal­iza­tions, pub­lished in The New Eng­land Jour­nal Of Medicine, showed that half of the pa­tients read­mit­ted within 30 days went from dis­charge to read­mis­sion with­out ever see­ing a physi­cian.

The right part­ner­ship be­tween hos­pi­tals, physi­cians and home health­care en­sures that pa­tients get the right level of post-acute care at home. That strat­egy of op­er­at­ing side by side en­ables pa­tients to func­tion bet­ter and pro- motes ad­her­ence to fol­low-up care that pre­vents avoid­able re­hos­pi­tal­iza­tions.

Monon­ga­hela Val­ley Hos­pi­tal is a case in point. In 2010, the fa­cil­ity’s read­mis­sion rate for heart fail­ure pa­tients reached 27%, nearly 3% above the national aver­age. It soon forged a col­lab­o­ra­tive ef­fort to in­te­grate with post-acute care providers to im­prove care for such pa­tients. Re­sult: read­mis­sions dropped to 14%.

We’ve all heard that health­care lives in si­los. And yes, the only align­ment that’s taken place is mis­align­ment. This has much to do with the fee-for-ser­vice model. The sys­tem once cre­ated ad­van­tages to be­ing ter­ri­to­rial. But the days when fee-for-ser­vice passed muster are fad­ing fast. Now, with health­care re­form here—par­tic­u­larly the CMS Read­mis­sions Re­duc­tion Pro­gram—we’ll all have to play as if we’re on the same team. We’ll have to shift from what we need to what pa­tients need.

Prop­erly co­or­di­nated care—with health­care pro­fes­sion­als aware of which di­ag­noses are made, which tests ad­min­is­tered, which med­i­ca­tions taken—will en­able all par­ties con­cerned to bet­ter man­age the sick­est of the sick. Such sym­bi­otic syn­er­gies will lower emer­gency room vis­its, read­mis­sion rates, lengths of stay, avoid­able read­mis­sions and ul­ti­mately im­prove pa­tient out­comes.

Or­ga­ni­za­tions such as Geisinger Health Sys­tem are al­ready get­ting this right, in part through its med­i­cal home model. As far back as 2008, Geisinger re­ported this ap­proach low­ered hos­pi­tal ad­mis­sions by 18% and over­all med­i­cal ex­penses by 7%

In­creas­ingly, as hos­pi­tals shift to­ward ac­count­able care or­ga­ni­za­tions and im­ple­ment bet­ter health in­for­ma­tion tech­nol­ogy, they’ll look to part­ner more with home health agen­cies.

A blue­print for the next steps

Health pro­fes­sion­als who de­liver care at home are well equipped to serve as eyes and ears for the pri­mary-care physi­cian (PCP). There­fore, the PCP par­tic­u­larly, but also nurses, ther­a­pists, so­cial work­ers and hos­pi­tals in gen­eral, must bet­ter align with home­care clin­i­cians de­ployed to co­or­di­nate care, es­pe­cially dur­ing and im­me­di­ately af­ter the cru­cial tran­si­tion from hos­pi­tal to home.

Hos­pi­tal physi­cians should con­tact posta­cute physi­cians re­spon­si­ble for the pa­tient, prefer­ably be­fore dis­charge. They should dis­cuss cases with an eye to­ward pre­vent­ing re­cur­rences. Hos­pi­tals should form care-tran­si­tion teams with a stan­dard pro­to­col for this hand­off from in­sti­tu­tion to home.

Physi­cians and hos­pi­tals should learn about home-care op­tions and dis­cuss those with pa­tients. The PCP should ini­ti­ate th­ese con­ver­sa­tions to reach an in­formed de­ci­sion about health­care at home.

De­spite wide­spread mis­per­cep­tions that health­care at home is merely baby-sit­ting, it is, in fact, a mul­ti­di­men­sional, mul­ti­dis­ci­plinary provider of su­pe­rior post-acute clin­i­cal ser­vice that is more di­rectly in­volved in pa­tient care than ever be­fore. The med­i­cal com­mu­nity, in­clud­ing med­i­cal schools and hos­pi­tal ad­min­is­tra­tors, must bet­ter demon­strate to pa­tients what health­care at home does, why it mat­ters, and how it makes a dif­fer­ence.

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