Feature Article
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Chronic Home Care: A Health Plans Experience From Senior Dimensions, Health Plan of Nevada, Sierra Health Services, Las Vegas, NV. Dr. Phillips is medical director, Ms. Smith is vice-president of Care Coordination, Ms. Cournoyer is manager of Chronic Home Care, and Ms. Hillegass is vice-president of Professional Services.
Senior Dimensions is the Medicare HMO program offered through Health Plan of Nevada, a wholly owned subsidiary of Sierra Health Services, Inc, Las Vegas, NV. The Chronic Home Care Program was presented as a poster at the American Geriatrics Society meeting in Washington, DC, on May 9, 2002. The work received the 2002 Model of Geriatric Care Award from the American Academy of Home Care Physicians.
Serving a diverse membership of elderly that includes both the acutely and chronically ill, Senior Dimensions, a Medicare Plus Choice program, has been working for well over a decade to find ways of utilizing home care as a means to prevent and/or reduce unnecessary hospitalizations and more effectively meet the needs and desires of those it serves. Many influences caused the development of our model of chronic home care: Medicare regulations, professional divergence, struggle between acute care treatment and chronic care management, as well as the understanding of a multidisciplinary approach.
One example of these influences was the difficulty of working within the Medicare home care guidelines—which are primarily designed for the intermittently ill—while we had a desire to provide more specialized care to our members with chronic issues.1,2 In 1996, these were combined with the implementation of a Social HMO demonstration program. Medicare beneficiaries receive enhanced services as determined by established criteria that are applied through a process of care coordination that allows more of a focus on our chronically ill population.3-6 We struggled to determine the best model of care to use. Experience told us that we needed the influence of both the medical and the social models of health care delivery to be successful. Additionally, we found that we needed to bring the program to the client, since interviews in the home allowed us greater insight into the client’s world. By synthesis, our Chronic Home Care Program has emerged.
PROGRAM DEVELOPMENT
The Social HMO (SHMO) provides care coordination for members identified with medical, psychological, functional, and social needs. We had observed that there was a segment of the population that would receive home health services until no further skilled-care needs existed and who, after being disenrolled from the traditional model of home health care, would later develop problems and end up going to the emergency room, hospital, or a skilled nursing facility. This was a recurring pattern that neither the patient, family, nor healthcare providers found acceptable. Based on these observations and needs, we developed a program to manage the chronically ill patient in the home. The overall intent of the program was to augment the care of such patients through an integrated approach that utilized the core principles of home health care that did not end when a skilled need was no longer present. The initial development of this program used the SHMO processes of case finding and screening to determine how members were selected for participation in the program. Admission criteria were reviewed by a geriatrician to ensure that principles of chronic care would be implemented.
The program was launched in 1999. We identified members within home care who would most benefit from continued care after discharge from skilled services. As the program developed, other eligible clients were identified by other providers involved in supplying care and services to members. Although there were individual successes in many cases, it became apparent that a home care team dedicated to this chronic home care population was required. In 2000, we further developed a special Chronic Home Care Program team and have continued to develop expertise in the care of this population.
The Chronic Home Care Program was formulated following the process of screening; assessment, and care plan development and implementation; and reassessment and modification of the care plan. Initial findings, change in patient condition, and plan of care are communicated directly to the primary care provider and specialists involved when appropriate. The Chronic Home Care Team was organized along the traditional home health care delivery model in addition to having a medical director for ongoing review and input. Charting was done within the chronic home care record, and all findings and plans of care were entered into a common database.
Screening: Definition of the Chronic Home Care Client
Selection criteria were based on health care events and member needs. The targeted population for the Chronic Home Care Program included members who met selection criteria in at least one of three categories. In the first category were all members with three or more hospitalizations in the previous six months related to one or more chronic illnesses. Illnesses most frequently leading to hospitalization included congestive heart failure, chronic obstructive pulmonary disease, diabetes, and dementia. The second category focused on members with specific home care needs, including those who could not get to the provider office for monthly Foley catheter change, had recently healed wounds that required ongoing nursing involvement to prevent further skin breakdown, and those with chronic wound care provided by the homebound client or family member who could not access the treatment center or provider office. The third category of participants included frail elderly and disabled members with multiple activity of daily living (ADL)/instrumental ADL deficiencies, malnourishment, or inadequate support systems. These members often required regular physical assessment more frequently than every 60 days and had issues with medication nonadherence that could be improved by weekly, biweekly, or monthly nursing visits.
Assessment and Care Plan Development and Implementation
The assessment tool allows the nurse care manager to identify medical, psychological, functional, and social needs of the client. In addition, the home environment, current health care resource utilization, and support systems are evaluated. For continuity of care purposes, the assessment tool has elements of the Outcome and Assessment Information Set Nursing Assessment and Home Evaluation imbedded within it.
A core principle of the SHMO program is that the client and/or family are instrumental and essential to the creation, ongoing evaluation, and modification of the plan of care. The SHMO program is intended to augment rather than replace existing services within the community. The chronic home care team maintains a close working relationship with local and state-supported agencies that serve the needs of the elderly and/or disabled population and frequently referred members to agencies that provided needed services. This includes Meals on Wheels, Senior Center Day Programs, Retired Senior Volunteer Program, and the state-sponsored Community Home Bound Initiative Program. Routine visits focused on individual needs, with all clients being screened in the following areas: (a) chronic disease knowledge; (b) medication set-up, knowledge, and adherence; (c) physical symptoms and signs; (d) adequate food and the ability to prepare and eat; (e) changes in social support; (f) basic safety; (g) functional ability; and (h) adequate community resources. The frequency of visits were determined by the Chronic Home Care Team along with input from the primary care provider.
Reassessment: Criteria for Recertification/Discharge from Chronic Home Care
Recertification of the chronic home care client was performed every 60 days and included an updated history and physical assessment. Re-evaluation of the plan of care included the following questions: • Are chronic home health visits needed? • Does the client need to be transferred to the skilled home care level? • Can the client be returned to an outpatient clinic setting? • Does the client require a more structured/super- vised care setting (Group Care, Assisted Living and/or Nursing Facility)? • Can the client be transitioned to hospice?
Updates were made in the plan of care to reflect changes in needs and treatment. The home care nurse discussed plans for discharge and transfer of care with the physician and client well in advance of discharge. A physician’s order was then obtained for discharge.
Termination of insurance, institutional placement including group home, improvement in health, and death were common reasons for discharge from the Chronic Home Care Program. Clients who were able to achieve their “state of best wellness” over a six-month period were frequently those who had no hospitalizations, were adherent with medications, were able and willing to regularly see their primary provider, were able to verbalize symptoms and signs of their disease process, and had adequate support systems.
Effectiveness of Program
When the Chronic Home Care Program was designed, it was not considered to study its effectiveness in a prospective manner. The SHMO is a demonstration project under the supervision of the Centers for Medicare and Medicaid Services (CMS), which considers not only patient outcomes but also the financial efficacy of not only the entire demonstration but its individual parts. For the analysis of the cost–benefit ratio, any element of the demonstration is important in evaluating whether that element should remain a part of the whole. Therefore, a plan to audit the success of the program was established during the developmental phase. The anticipated general outcome was reduction of hospital days for members identified for the Chronic Home Care Program. March of 2001 was selected as the date for the audit. Clients being served at that time were selected as the population for review. From that population, all clients who had been active for at least six months were evaluated to determine bed-day utilization six months prior to admission to chronic home care as compared with six months after admission. The sample included 91 clients. The audit included acute hospital days, subacute hospital days, and skilled nursing facility days.
In the six months prior to admission to chronic home care, clients in the sample utilized 351 hospital days, 531 sub-acute days, and 21 skilled days. In the six months after admission to chronic home care, these clients utilized 133 hospital days, 91 subacute days, and 60 skilled days. Bed-day savings for the audited population were also appreciable. There was a savings of $439,825 (cost for acute bed-day, $1200; subacute bed-day, $425; and skilled bed-day, $225). Subtracting the cost of the Chronic Home Care Team at $178,600, total savings for the Chronic Home Care Program over a six-month period equaled $261,225 (Table).
The initial audit indicates this program had a positive impact on bed-day utilization. The program also resulted in increased member satisfaction. Members and their families participating in the program had less than a 1% complaint ratio regarding services provided and needs being met. While the program shows success, Senior Dimensions continues to refine and enhance processes to include anticipation of end-of-life needs through social service and hospice.
OBSTACLES MET AND LESSONS LEARNED
Although initial criteria for enrollment in the program existed from its inception, ongoing review and refinement throughout the implementation stage was required. We initially assumed that all clinicians would have the same concept of “frail individuals.” The lesson learned from launching the program without significant training about chronic frail members was that patients were seen who in fact did not need this intensive follow-up. Continued communication about the program was essential for success. To decrease the risk of having far too many patients to manage, thus reducing the potential for savings, an ongoing routine review of the cases by leadership was required. Annual program review was also essential for success. Conducting an audit as described earlier allowed leadership to analyze the cost–benefit effectiveness and provided clinicians with a sense of accomplishment for patients that they may have previously felt incapable of caring for.
The introduction of a monthly meeting with the Medical Director of Senior Dimensions Extended Care and the Chronic Home Care Team has improved staff development and satisfaction. The review of difficult cases and at times role playing has made the team more cohesive and aware of the tremendous role they serve within the organization.
One recurring theme is the difficulty in accessing the provider for their clients. There is the usual scheduling difficulty along with the arrangement for transportation due to a population with significant functional/mobility impairments. This has led to the decision for the incorporation of a physician/extender house call component into the chronic home care model.
POTENTIAL FOR REPLICATION
The success of a Chronic Home Care Program is dependent upon adequate financing, provider education, and acceptance. Within traditional Medicare, fee-for-service/dependent health care delivery models, the incorporation of a physician/extender group along with the home health care agency allows for ongoing patient management. Current federal reimbursement regulations allow for both a home health agency and physician/extender provider group to be in the home at the same time. After the home health agency discharges the patient from service, the physician/extender group is able to remain involved and continue to provide for and coordinate the ongoing needs and services of the patient. Within a managed care environment such as Medicare Plus Choice, the health care organization can certainly replicate the entire program. A well-developed and coordinated Chronic Home Care Program as described can truly enhance the organization’s long-term viability and profitability.
Within both funding models—traditional Medicare and Medicare Plus Choice—the approach to educating the provider community is similar. This includes the providers, administrators, hospitals, home health agencies, nursing facilities, and community organizations affiliated with the health care system. The identification of champions within each entity of the health care system is necessary. These individuals are able to represent and promote the concepts, admission criteria, and available services that are essential to a successful Chronic Home Care Program.
CONCLUSION
The implementation of a Chronic Home Care Program has reduced the usage of acute and subacute bed-days in this group of 91 health plan members. There are limitations to the comparison of bed-day utilization six months prior to enrollment in the program with subsequent utilization while on the program for six months. Ongoing evaluations do continue to demonstrate an overall cost savings for the health plan. The Chronic Home Care Program has recently been expanded and is serving a total of 250 health plan members. Data is now being collected prospectively to further illustrate the patient population served, functional limitations, and average length of stay on the program. Clients on the program are being assessed for the characteristics of those that return to the ambulatory clinical care setting, require institutional care, or are referred to hospice services with the outcome of eventual death.
The implementation of a program that utilizes home health services and primary care providers can effectively meet the needs of the population described. There are many reasons for offering a Chronic Home Care Program, even if one cannot implement all of the services that are required for a specific patient. An example is a patient with a chronic condition presenting at the emergency room who may have come for nothing more than some comfort care. The mindset of the emergency room and hospital staff is to manage acute conditions. Unfortunately, for many chronically ill patients who are incapable of accessing care from a clinic/office setting, the emergency room becomes their usual site of care. Primary care physicians who understand the management principles involved in caring for chronically ill older adults are in a position to champion the development and implementation of a Chronic Home Care Program within their community. The potential for improving care for the at-risk, vulnerable patient population and for reducing unnecessary emergency room visits, hospitalizations, and readmissions within 30 days of discharge is a worthy goal to pursue.
References 1. Home Health Agency Manual. Health Care Financing Administration. Pub 11, section 208.4;1996. 2. Welch HG, Wennberg DE, Welch WP. The use of Medicare home health care services. N Engl J Med 1996;335(5):324-329. 3. Finch M, Kane RA, Kane RL, et al. Design of the 2nd generation S/HMO demonstration: An analysis of multiple incentives. Report prepared for the Health Care Financing Administration. Minneapolis, MN: University of Minnesota;1992. 4. Kane RL, Kane RA, Finch M, et al. S/HMOs, the second generation: Building on the experience of the first Social Health Maintenance Organization demonstrations. J Am Geriatr Soc 1997;45(1): 101-107. 5. Boult L, Boult C. Innovations in the Second Generation of Social Health Maintenance Organizations. Current Concepts in Geriatric Managed Care 1997;3:3-12. 6. Phillips SL. Toward a Systematic Approach for the Improvement of Health-Care Delivery to Older Americans. Current Concepts in Geriatric Managed Care 1996;2:4-10.
(Annals of Long-Term Care:Clinical Care and Aging 2004;12[4]41-45) Annals of Long-Term Care - ISSN: 1524-7929 - Volume 12 - Issue 04 - April 2004 |