A Solution for the Frail Elderly Population

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.