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Home Care Heroes Blog

Care Coordination Opportunities for Home Care & Home Health

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The title of this blog should read more accurately “How Private Duty Home Care, Home Health Care, Therapy agencies, Infusion, Geriatric Care Managers, those providing care for the elderly or planning for care transitions can THRIVE in this era of Health Care Reform” …. BUT that just doesn’t fit in the title block.

CareMore Hospitalization rate

Put the incentives in the hands of those who deliver care and solutions that include telehealth monitoring, wellness coaching, early preventive care, toenail clipping, and free rides to appointments will take over.  When organizations are accountable for the results and the costs, incentives are aligned. Providers are no longer consumed with fee for service and they are rewarded for being effective and efficient.  These models can simultaneously improve the quality of care and reduce overall costs.

CareMore Improved Outcomes without increasing costs

Here’s proof – and every Private Duty home care agency, Medicare certified Home Health agency, hospital, and physician providing Geriatric Care had better get on board:

CareMore logo

CareMore, now owned by WellPoint, started bucking the fee-for-service trend in healthcare decades ago. CareMore’s founder, Dr. Sheldon Zinberg, envisioned a coordinated care model for the elderly that focused on early interventions and preventive care.

A lesson from business: A problem that costs $1 to solve early will cost you $30 to solve if you wait for it to become a big problem. It’s a principle proven repeatedly over the last 80 years or so since Deming first explained it and it is a fundamental axiom of business. Toyota and Proctor & Gamble live by it, and it drives a culture of both quality and cost management. Accountable Care Organizations understand it and will embrace it, as well.

The Atlantic logo

Consider this example, all too common with elderly patients, borrowed from “The Quiet Healthcare Revolution,” in November issue of The Atlantic Monthly and written by Tom Main and Adrian Slywotzky.

“Ellen, an 82-year-old widow, lives in Anaheim, California. One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds—wasn’t that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran.

Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen’s weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen’s scale had transmitted its reading to the clinic over a wireless connection.

Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen’s treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization. “

Another example from the same article in The Atlantic:

“Dan, a retired letter carrier, is a patient at a clinic in the same system. At 87, he is decidedly frail, his once-sturdy legs now weak and unsteady. He is a classic candidate for a fall of the kind that has injured many of his friends, in some cases leading to weeks in the hospital and months of rehab. The elderly are prone to falls for many obvious reasons, including weak limbs, impaired vision, and medication side effects. But Dan’s doctors knew that some less obvious causes included shag carpets and long, untrimmed toenails. Because of this, they’d sent someone from the clinic to visit Dan’s apartment and make sure that his daughter replaced the 1980s-vintage carpets with low-pile rugs. Dan also visits the clinic regularly for light muscle-training sessions and periodic toenail clipping. Due to these preventive measures, Dan and his fellow clinic patients are one-fifth as likely as comparable patients elsewhere to suffer falls.”


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Ankota's XChange Care Coordination Portal helps providers coordinate roles and assignments in Accountable Care models such as these. The Xchange Care Coordination Portal is part of Ankota's Healthcare Delivery Management technology (HDM), which helps individual providers make their own operations more productive and efficient.


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