• more than one HbA1C that is greater than 7% and/or
• LDL-C greater than 100 mg/DL and/or
• blood pressure readings of greater than 140/90 and/or
• individuals who smoke tobacco

Once the patients are identified, the next step would be to define and implement a plan for patient and family education and intervention.

When looking at the Accountable Care Coordination Analysis documentation published on the CMS web site, diabetes patients are a key part of the at risk population section.

Care Transition and Coordination of Evidence-Based Care

As the patient transitions from one care setting to another, it is important to address those areas that are often a concern, such as summary of care provided by previous setting, medications, follow-up with primary care provider, and maintaining a comprehensive record.

There are several care transition models available in the public domain. Contact the Quality Improvement Organization in your State for guidance, or access the Institute for Health Improvement for information about the State Action on Avoidable Rehospitalizations (STAAR) initiative.

Being aware of the high-cost areas of care, identifying risk factors applicable to the individual patient, and working with the physician, the patient and the family to establish a reasonable and evidence-based plan of care will be imperative. Evidence-based approaches to care are available for numerous disease processes and co-morbidities from public sources.

Consistent Reporting and Communication

Clear documentation of every evaluation of the patient, each communication with the physician and other providers, each communication with the patient and/or a family member, all tests, measures, etc. should be included in the patient health record. With comprehensive documentation, reporting of outcomes, trends, etc. can be gathered. Utilization of an electronic health record solution for all documentation will allow for data mining of information both at the patient level and at the population level.

The sharing of information between providers is imperative to make certain that every provider has the same information from which to make decisions regarding patient care. Whether the information is shared electronically through continuity of care documentation included in the HITSP C32 (National Institute of Standards and Technology, March 2009) or on paper utilizing a standardized form of communication such as SBAR (Situation, Background, Assessment, Recommendation) (Institute for Healthcare Improvement) and/or discharge summaries, the overarching factor is to communicate and coordinate.

• Catheter related bloodstream infections (CRBSI),
• Catheter-associated urinary tract infections (CAUTI),
• Clostridium difficile infections (CDI), and
• Surgical site infections (SSI)

These infections, though not reported for outcome measures by home care, could be integrated into the practice model for the home care clinicians, where applicable, as far as risk identification, interventions, agency monitoring, etc.

References: U.S. Department of Health and Human Services. August 3, 2011. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations. Federal Register, Vol. 76, No. 149, pp. 46814-46818.

For Medicare recipients receiving home care services between 1997 and 2009, diabetes and heart failure are the leading principle diagnoses for the patient population (Center for Medicare and Medicaid Services, 2010).  Coordination of evaluations and interventions between the home care provider and the physician(s) would allow for a repetitive and comprehensive approach to the care of the patient.

The Department of Health and Human Services published a Surgeon General’s report that indicates that counseling and pharmacologic treatments such as nicotine replacement therapies and bupropion are effective for smoking cessation (U.S. Department of Health and Human Services, 2010). Home care could support the smoking cessation efforts for hospitals and physicians by integrating appropriate interventions in the plans for the care of the patient. Reporting, though not public, could further strengthen marketing efforts for home care providers with referral sources.

1. Influenza
2. Pneumococcal

Immunizations are an integral part of avoiding hospitalization.  Nichol KL, Wuorenma J, and von Stemberg (as cited by the Center for Disease Control, August 6, 2010) report a ‘substantial reduction in hospitalization and deaths among persons aged 65 and greater with influenza immunization’.

Furthermore, the Georgia Department of Public Health reports “Among elderly people living outside of nursing homes or similar chronic-care facilities, influenza vaccine is 30-70% effective in preventing hospitalization for pneumonia and influenza”. The Center for Disease Control and Prevention (CDC) also reports that “pneumococcal vaccine is very good at preventing severe disease, hospitalization, and death (April 1, 2011). 

The majority of hospital readmission costs are associated with four distinct medical conditions, which lead to over $1.6 billion in spending on readmissions alone.  These conditions include heart failure, chronic obstructive pulmonary disease (COPD), pneumonia, and acute myocardial infarction (AMI) (MedPAC, June 2007, p.116).  Granted these numbers are based upon 2005 Medicare hospital discharges and they could be even higher in 2011.

Hospitals currently report on re-admissions for patients discharged with one of three particular principal diagnoses:

1. AMI
2. Heart failure
3. Pneumonia

National averages for hospital readmissions as of August 5, 2011, were still over 15% at 19.8, 24.8 and 18.4% respectively (U.S. Department of Health and Human Services, August 5, 2011).

Home care hospitalization outcomes are reported with a national average of 26% (U.S. Department of Health and Human Services, July 21, 2011).  The Delta Study to Reduce Hospitalizations:  A National Study to Reduce Avoidable Hospitalizations through Home Care will identify practices used by the most successful home care agencies to help reduce their rate of avoidable hospitalizations.  The Delta Study to Reduce Hospitalizations report will be shared with the home care industry at large in February 2012.

While physicians’ quality measures do not focus on hospital admission specifically, the focus is on interventions and treatment to prevent disease, disease progression, and ultimately avoiding hospitalization. 

1. Better care for individuals
2. Better health for populations
3. Lower growth in health care expenditures

With so much focus on the hospital and physician providers, how can home care, a lower cost provider, substantively contribute to accountable care objectives?

Hospitals and physicians both participate in quality reporting, as does home care.  In fact, there are several measures that are either already publicly reported by one or more of the aforementioned providers or could be effectively measured by all three.

1. Decreasing avoidable hospitalizations
2. Immunizations/vaccines
3. Screening/prevention measures
4. Decreasing infections
5. At risk population identification and intervention

Each of the aforementioned areas will be discussed in upcoming blogs.

Home care providers, by being aware of what is being measured by the hospital and physician providers, and through collaborative care and the adoption of evidence-based best practices that focus on three main areas of disease (diabetes, heart failure, and pneumonia, at a minimum), could make a substantive contribution to the accountable care goals of quality of care for individuals and populations, along with cost containment.  Such efforts will most likely provide positive sales, marketing, and partnership opportunities for the savvy home care provider.

Reference: U.S. Department of Health and Human Services.  November 2, 2011. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations.  Federal Register, Vol. 76, No. 212, pp. 67802- 67990.

No ethical member of the home care community would condone defrauding the Medicare program. The Senate inquiry was not at all a surprise after the April 26, 2010 Wall Street Journal article, which first brought the potential gaming issue to light. The three companies mentioned represent less than 17% of Medicare providers of home care services. The vast majority of home care providers, numbering more than 10,000, provide services that are desperately needed by our senior citizens to recover from surgery, falls and complications from chronic conditions. 

The goal of Medicare home care has shifted in recent years from hands-on “doing” for patients to rehabilitating the patient to a maximum level of independence, a shift that we would all support.  Nursing services, while including patient education, more often focus on addressing the specific medical care that is needed.  Therapy services on the other hand, focus on increasing the patient’s strength and ability to return to independent living.  This explains the special emphasis on therapy in the Medicare reimbursement regulations.  Access to Physical, Occupational and Speech-Pathology Therapists is quite limited and therefore costly.  Special reimbursement for these services makes sense and is needed.

So, how did the home care industry react to the increased scrutiny and fallout?  Rather than protest the article as being unfair or launching a public relations counter-offensive, the industry came together to constructively focus on how to determine the appropriate use of home-based therapies.  The National Association for Home Care & Hospice (NAHC), the American Occupational Therapy Association (AOTA), American Speech-Language-Hearing Association (ASHA), and the Home Health Section of the American Physical Therapy Association(APTA), convened a meeting of home care experts from around the nation to establish tips and strategies to ensure appropriate allocation of rehabilitation services for each patient in a manner tailored to meet the individual’s clinical needs.  This information was then provided to the entire home care community at no cost.  Free copies of the full report can be downloaded at www.deltahealthtech.com/research/projects/Therapies.*

Allow the Senate investigation to continue and punish any and all who have cheated the taxpayer but let’s protect the reputation of the majority of home care agencies, and individual care givers, as the providers of necessary and compassionate services.  Let us not deny access of quality rehabilitation services to our senior citizens who need these services to remain independent and at home.  

*The study was funded by Delta Health Technologies and conducted by Fazzi Associates.

Delta Responds to Questioning of Integrity of Home Care

We recently worked with a marketing firm to establish a brand narrative for Delta Health Technologies.  A brand narrative is intended to tell a company’s unique story, the story of their culture, the story of what makes the company different.  The narrative is built by interviewing the company’s staff and customers to understand what is unique about the company, its products and services.   The marketing company, Varsity Branding, then presented three different versions of the narrative to Delta’s leadership to see which of the three resonated as being the most true to the company’s core values and unique value proposition. 

The brand narrative asks the question, “Can technology care?” and contains statements of why the company believes the answer is “yes”.  Can technology care?  It can when it helps clients run their operations smoothly, when it makes their processes run more smoothly, when it enables them to spend more time and effort on their clients.  So reads Delta’s brand narrative, in part.

This is the ultimate corporate, coffee-table book.  It is not intended to become ad copy or to become part of the company’s web presence…necessarily.  But it is to be a guide against which all marketing is to be compared.  All formal communication is held up to the brand narrative to see if the messaging rings true to the company’s story of itself.   Our premise is that technology, namely a technology company, can and does care.

Conversely one of my favorite bloggers, Seth Godin, blogged on the topic of Caring on May 27. Seth wrote,

No organization cares about you. Organizations aren’t capable of this.

Your bank, certainly, doesn’t care. Neither does your HMO or even your car dealer. It’s amazing to me that people are surprised to discover this fact.

People, on the other hand, are perfectly capable of caring. It’s part of being a human. It’s only when organizational demands and regulations get in the way that the caring fades.

If you want to build a caring organization, you need to fill it with caring people and then get out of their way. When your organization punishes people for caring, don’t be surprised when people stop caring.

When you free your employees to act like people (as opposed to cogs in a profit-maximizing efficient machine) then the caring can’t help but happen.

I’m not sure whether I agree or disagree.  Delta is a caring organization comprised of caring employees who have been freed to act like people.

What do you think?  Can technology care?  Can technology companies care?

Seth Godin, “Caring,” Seth Godin, May 27, 2011 (http://feedproxy.google.com/~r/typepad/sethsmainblog/~3/8OzYJdJXZjc/caring-965.html)