Healthcare at home

For a long time, many of us healthcare professionals have operated largely within our own comfort zones. We do just as we've always done, acting independently of each other, as if in our own private universe. We saw little incentive to change, least of all soon.

That's happening less often now, thanks mostly to pressures for healthcare reform from the federal government and private sector alike. But our approach to caring for patients remains fragmented. We're still going to have to break free of those comfort zones.

Nowhere is this disjointed format more evident than in the relationship between the healthcare profession as a whole and organizations that specialize in delivering healthcare at home. That's a shame, given increasing evidence that with our population living longer, often with chronic illnesses, a growing segment of patients may be better served at home than in institutions.

Our population, it turns out, has moved ahead of our healthcare infrastructure. As a result, vast needs are going unmet. Some patients are going without healthcare at home, depriving them of essential therapeutic services to improve basic functions we all take for granted.

For decades, nobody in healthcare really had to talk all that much to anyone else; that held true for dialogue between hospitals and home health agencies. Indeed, a 2006 survey by Press Ganey, “Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices,” found that more than 80% of patients who required help with basic functional needs never received a home healthcare referral. For that matter, a 2009 analysis of Medicare rehospitalizations, published in The New England Journal Of Medicine, showed that half of the patients readmitted within 30 days went from discharge to readmission without ever seeing a physician.

The right partnership between hospitals, physicians and home healthcare ensures that patients get the right level of post-acute care at home. That strategy of operating side by side enables patients to function better and promotes adherence to follow-up care that prevents avoidable rehospitalizations.

Monongahela Valley Hospital is a case in point. In 2010, the facility's readmission rate for heart failure patients reached 27%, nearly 3% above the national average. It soon forged a collaborative effort to integrate with post-acute care providers to improve care for such patients. Result: readmissions dropped to 14%.

And yes, the only alignment that's taken place is misalignment. This has much to do with the fee-for-service model. The system once created advantages to being territorial. But the days when fee-for-service passed muster are fading fast. Now, with healthcare reform here—particularly the CMS Readmissions Reduction Program—we'll all have to play as if we're on the same team. We'll have to shift from what we need to what patients need.

Properly coordinated care—with healthcare professionals aware of which diagnoses are made, which tests administered, which medications taken—will enable all parties concerned to better manage the sickest of the sick. Such symbiotic synergies will lower emergency room visits, readmission rates, lengths of stay, avoidable readmissions and ultimately improve patient outcomes.

Organizations such as Geisinger Health System are already getting this right, in part through its medical home model. As far back as 2008, Geisinger reported this approach lowered hospital admissions by 18% and overall medical expenses by 7%

Increasingly, as hospitals shift toward accountable care organizations and implement better health information technology, they'll look to partner more with home health agencies.

Health professionals who deliver care at home are well equipped to serve as eyes and ears for the primary-care physician (PCP). Therefore, the PCP particularly, but also nurses, therapists, social workers and hospitals in general, must better align with home-care clinicians deployed to coordinate care, especially during and immediately after the crucial transition from hospital to home.

Hospital physicians should contact post-acute physicians responsible for the patient, preferably before discharge. They should discuss cases with an eye toward preventing recurrences. Hospitals should form care-transition teams with a standard protocol for this handoff from institution to home.

Physicians and hospitals should learn about home-care options and discuss those with patients. The PCP should initiate these conversations to reach an informed decision about healthcare at home.

Despite widespread misperceptions that healthcare at home is merely baby-sitting, it is, in fact, a multidimensional, multidisciplinary provider of superior post-acute clinical service that is more directly involved in patient care than ever before. The medical community, including medical schools and hospital administrators, must better demonstrate to patients what healthcare at home does, why it matters, and how it makes a difference.

Michael Fleming is former president of the American Academy of Family Physicians and chief medical officer of Amedisys Home Health and Hospice Care.