The Future of Home Health Care: Workshop Summary by Victoria Weisfeld

Author:Victoria Weisfeld
Language: eng
Format: epub
Publisher: The National Academies Press
Published: 2015-08-18T00:00:00+00:00

Communication and Teamwork

Although the visiting nurses complete the usual lengthy intake forms that assess patients for everything from the risk of falls to the medications that they take and the presence of depression, these records are often not well incorporated into the patients’ records, Lopez said. Atrius’s electronic health records system ensures that current assessments appear where they are convenient for physicians to access. Practice care managers receive a weekly email report on clinical data for active patients. The report includes progress toward goals, response to teaching, discharge planning, and any hospice team meeting notes. The report is then distributed to physicians. (Lopez noted that the Atrius system uses encrypted email for communication among providers.)

Atrius has instituted an automated referral system through the electronic health records, so that when a referral is made it goes to VNACNH intake staff, who can then access the patient’s record to set up the case for VNACNH. At present, VNACNH uses an end-of-life information system, and Lopez said that Atrius is considering adopting a home health care module in the next year or two to make records more fully integrated.

A steering committee comprising senior staff oversees the development of the Atrius-VNACNH relationship and clarifies policies and procedures to ensure care coordination and collaboration, Lopez said. In addition, many specific activities have been undertaken to transform VNACNH’s relationship with Atrius Health from one in which VNACNH is a vendor to one in which VNACNH and Atrius have a true partnership.

In primary care practices, Lopez noted that an effort has been made to integrate members of the patient-centered team with VNACNH staff in relevant places along the continuum of care. In particular, work has concentrated on educating practice staff about palliative care and end-of-life challenges, he said. Another specific team-building strategy is “geriatric roster reviews,” which are regular team meetings in the doctor’s office in which case reviews are done for patients identified to be at high risk.

Program Design and Metrics

VNACNH has developed a palliative care consult team that works with the primary care practice and the home health care staff to better manage patients near the end of life, and it also has a robust advance care planning program. According to Lopez, one goal of the end-of-life efforts is to encourage earlier hospice enrollment, contrary to current practice patterns in Massachusetts, which overall has one of the nation’s shortest hospice lengths of stay. “A lot of low-hanging fruit is there,” Lopez said, as Atrius attempts to improve quality and reduce costs of care.

The system has developed a one-time-visit home assessment system paid for not through Medicare but by the physician groups. They assess patients’ homes for safety and adequacy as a care environment. Atrius’s total joint program, also paid for by the physician groups, enables patients to undergo rehabilitation at home rather than in a skilled nursing facility or inpatient rehabilitation facility. Those who can go home with help after knee or hip replacement incur about $3,500 less in care costs and have the same or better outcomes, Lopez said.

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