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Transitions to Home Care Getting More Attention

Transitions to Home Care Getting More Attention

By Jennifer Larson, contributor

October 29, 2010 – A growing number of health care professionals hope to find ways to achieve better transitions for patients who are discharged from the hospital to their homes.

To that end, the inaugural Optimizing Home Health in Care Transitions Summit was held on October 26 in Philadelphia to get the discussion going. The summit was sponsored by the University of Pennsylvania School of Nursing, with the Alliance for Home Health Quality and Innovation and The Joint Commission.

“There are better ways to do things,” noted Steven Landers, M.D., one of the keynote speakers at the summit and the director for the Center for Home Care and Community Rehabilitation at The Cleveland Clinic.

If the group’s efforts are successful, it could help reduce the number of unnecessary hospital readmissions—a goal that gained prominence in 2009 when the New England Journal of Medicine published a major study that found one-fifth of all Medicare beneficiaries who were discharged from the hospital were readmitted within 30 days.

It’s possible that many of those readmissions could have been prevented with better discharge planning and follow-up, according to the study. The readmission problem is an expensive one, too, costing more than $17 billion in 2004 alone.

In the past, there was not much emphasis placed on the transition between hospital and home, Landers said. Some people did—and do—receive home care services after being discharged, but not everyone who could benefit from such follow-up care has received it. This situation began to change when the Centers for Medicare and Medicaid Services (CMS) decided to address the matter.

Not long after the NEJM study appeared, CMS launched a nationwide pilot program, the Care Transitions Project, with the goal of reducing preventable hospital readmissions for Medicare patients. Fourteen community sites were chosen to improve the processes that could help them achieve that goal. Each of the communities is working with a state quality improvement organization on the project, which will run through 2011.

In addition, the federal Patient Protection and Affordable Care Act, which was passed by Congress in March, authorized CMS to penalize hospitals with excessive readmission rates.

As the population ages, and the number of older adults with multiple chronic ailments increases, there could be an even greater need for a solution that would provide high quality care without driving up costs. An efficient transitional care model could be that effective solution, Landers said.

The trend toward increasing and expanding the role of transitional care appears to be gaining momentum.

“Transitional care is a very hot topic right now in the health care world,” Landers confirmed, adding that the most promising models include good discharge planning and post-hospital home visits.

Until recently, there was not much interest in working across various health care settings, noted David Wenner, D.O., FAAFP, medical director for Quality Insights of Pennsylvania. That is changing, however, as the health care industry realizes that improving communication among providers can increase the chances that a patient will receive the appropriate follow-up care and education necessary when transitioning from the hospital or a skilled nursing facility to their home.

Wenner would like to see a better utilization of the mobile health care work force; he noted that home health nurses have a unique opportunity to see where a patient lives and gain insight into their situation at home. For example, they can see that a patient may not have a car to drive himself to a pharmacy to pick up vital medications, or family members living nearby to help out.

Home health nurses also have the chance to educate patients after discharge to make sure the patients know how to care for themselves. By contrast, the patient’s doctor may not have the same understanding of the patient’s life outside the hospital or exam room. So they must be able to work together in a cross-setting approach.

Also, most communities have a home health presence, Landers added. Their services could be expanded to address the needs of patients who could benefit from more transitional care.

Another crucial role that home health nurses could play is coaching patients to feel comfortable with what they have learned about caring for themselves and helping them to feel confident in doing so. In Pennsylvania, the CMS-funded project has been using social workers to do this type of coaching, but the goal is the same: helping patients understand what they need to do to be able to remain in their homes. After all, in most cases, “you’re not going to have a home care nurse or a physician in your home 24/7,” Wenner said.

Like a growing number of health care leaders, Landers believes that the home care trend is already on the rise. He authored a commentary that appeared in the New England Journal of Medicine in October 2010 that predicts home-based health care will eventually prevail over facility-based care. With better care coordination, technological improvements and support for patients, home care has a couple of key benefits: patients get to stay in their homes, and it saves money.

So the drive toward home care is not only possible but inevitable, he said, although it could take years to fully realize.

“And most people prefer it,” Landers added. “Most folks want to be at home.”