By: Robert Ellis
In 2014, Medicare fined a record 2,610 hospitals (out of
3,353 subject to the Hospital Readmission Program) an estimated $428 million in
penalties for having high readmission rates for certain diagnoses (i.e. heart
failure, heart attack, pneumonia, knee or hip replacement, and lung ailments).
In 2013, nearly 18 percent of Medicare patients who had been
hospitalized for one of five conditions studied was readmitted within 30 days
of hospital discharge, according to Kaiser Health News. Roughly, 2 million
patients return a year, costing Medicare, $26 billion. $17 billion of that
expense comes from potentially avoidable readmission.
WHAT ARE WE DOING TO
DECREASE THAT NUMBER?
TLC HomeCare is an Upper Valley, New Hampshire &
Vermont, home care organization providing services for patients being
discharged from 4 community hospitals, a large VA Medical Center, and Dartmouth-Hitchcock
Medical Center (a tertiary care center in the midst of it all). The Upper
Valley of New England is in the center of New Hampshire and Vermont, and TLC
HomeCare has a service area in both states.
Most of the patients/clients discussed above share many
common similarities; most are above the age of 65, most have co-morbidities
(multiple diagnoses), and polypharmacy (multiple prescriptions). Many do not
have adequate support systems in place in an area that is very rural in nature.
Some of these patients/clients, have skilled nursing needs at the time of
discharge, and those services will be covered under the Medicare benefit for Visiting
Nurse services. Examples of skilled nursing are; catheter changes, wound
dressing changes, IV drug administration, ect.. But a large number of these discharged patients/clients
do not have a skilled nursing need and therefore do not qualify for Medicare
reimbursement for visiting nurses. This is the population that is at the
highest risk of non-compliance and potential readmission stemming from
complications. It is also the population that TLC HomeCare is most concerned
about. TLC is actively discussing with its partner hospitals, its integration
into a care transition program for that population that does not qualify for
the Medicare benefit but have a need to provide assistance to the patient and
the family in the management of the first 30-90 days of discharge care
coordination.
TLC HomeCare uses a service model that provides nursing
oversight for all of their patients/clients. The initial assessment after
discharge is done by a RN (registered nurse) case manager, who completes a
complete physical and cognitive assessment and designs a care plan that is
followed by the caregivers in the patient/client home. The longitudinal care is
provided by LNA’s, CNA’s and PCA’s. In this way, TLC HomeCare can keep the
costs of services at a more reasonable rate, while still providing RN Case
Management for all of its clients. Examples of non-skilled nursing services
are; medication reminders, assistance with bathing and dressing, light housekeeping,
laundry and meal preparation.
Among the techniques used to reduce readmission rates has
been the inclusion of a timely follow-up visit with a primary care physician.
At these appointments, discharge directions can be reinforced, medications
reviewed, lingering issues addressed, and questions answered. If needed, at
that time, care plans can be revised. TLC HomeCare, will also provide
transportation and companionship to these important follow-up appointments at
the doctor’s office or the hospital.
At the present time, these services are not covered by
Medicare, and are paid by either long term care insurance or out-of-pocket by
clients or their families. With an aging US population, the hope is that over
time, the importance of the longitudinal post discharge services provided by
TLC HomeCare will be fully integrated into the care coordination of this frail
elderly population.
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