Project ID: 2.b.viii
Project Name:
Hospital-Home Care Collaboration
Project Description:
Solutions for hospital-home care collaboration
Project Chairs:
Laurie Neander, At Home Care
Carlton Rule, MD, Tri-Town Regional Hospital
Objective:
Implementation of INTERACT-like program in the home care setting to reduce risk of re-hospitalizations for high risk patients.
Rationale and Relationship to Other Projects:
Many patients who previously were transferred to skilled nursing facilities are now being discharged to lesser restrictive alternatives, primarily their own home. With the many benefits of returning to a known and personal setting, there are the risks of potential non-compliance with discharge regimens, missed provider appointments and less frequent observation of an at-risk person by medical staff. This project will put services in place to address this problem. It may be paired with transition care management but the service would be expected to last more than 30 days.
Core Components:
This program should be implemented based upon the evaluation of the community assessment evaluation for causes of avoidable admissions and readmissions. The following are core components of this program that will need to be established by the PPS through coordination with participating hospitals including emergency rooms and pharmacy services, home care services, primary care physicians and specialty services:
- Rapid Response Teams (hospital/home care) to facilitate patients’ discharges to home including assuring needed home care services are in place.
- Home care staff with knowledge and skills to identify and respond to patient risks for readmission and to support evidence based medicine chronic care management.
- Development of care pathways and other clinical tools for the monitoring of chronically ill patients with the goal to identify early potential instability and allow intervention to avoid hospital transfer. Education of all staff on care pathways and INTERACT principles.
- Development of Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care.
- Coaching program to facilitate and support implementation.
- Education of patient and family/caretakers on the initiative and empowering them to participate in planning of care. This should include support of the family/caretakers as well as potential for respite services.
- Integration of primary care, behavioral health, pharmacy and other services into the model to enhance coordination of care and medication management.
- Utilization of telehealth/telemedicine.
- Utilization of interoperable EHR to enhance communication, avoid medication errors and duplicative services.
- Measurement of outcomes including quality assessment/root cause analysis of transfer to identify interventions.
- Demonstration of clear cultural competence and willingness to engage Medicaid members in the design and implementation of system transformation including addressing issues of health disparities.