Engaged patients, famillies and caregivers can help lower medical costs, reduce hospital admissions, and improve health behaviors. The patients' health has a greater chance for improving when the family and caregivers can better communicate the importance of incorporating a healthier diet, increasing levels of physical activity, and medication compliance for chronic diseases management. However, recent data on health care consumers found that 1 in 3 patients are disengaged in their own care. Meaning that patients did not have a clear understanding of their diagnosis and conditions, and they weren’t actively working towards better self-management and care.
Language, cultural background, and previous experiences in healthcare can have a signficant positive or negative impact on one's approach to health care. With patients, families, their caregivers, and health professionals working in active partnership at various connecting points of care older patients with chronic conditions can have a more positive care experience, and realize reduced risks and complications. For example, during a hospital admission or discharge, providing patients and families with detailed information and walking them through discharge planning throughout the hospital stay can reduce issues post-discharge. Perhaps, more importantly, what really works is improved and ongoing post hospitilization communication that encourages patients and family members to participate as advisors. As the advisor, they become more aware of medication and community resources, recognize and connected with support services and health care professionals as a diversion to readmissio and acute care services?
For decades, non-clinical home care agencies, therapists, and aides have been caring for chronically ill patients in their homes. Rather than moving into a long-term care facility as they age, many older adults prefer to stay at home for as long as possible. For those older adults choosing to stay at home, determining the range of non-clinical home care services available to help maintain their independence can be daunting. Non-clinical home care providers may have meet unique qualifications that help patients and providers reach overall goals for chronic care management, self-care, and independence. This often includes required services and supports not covered under Medicare’s home health or acute care benefit.
Home care is provided by caregivers, generally recognized as home care aides, who are trained to understand the nuances of senior care. Home care aides can help older adults with activities of daily living, or just offer some friendly companionship. Unlike home health, home care is classified as personal care or companion care and is considered "unskilled" or "non-clinical." Medicare will generally provide coverage for skilled nursing or therapy at home, and for limited visits by an aide from a home care agency to help with personal care. For Medicare patients eligible to receive skilled home care benefits, Medicare also covers the services of an occupational therapist to assist older adults with becoming stronger in accomplishing daily personal care and household tasks safely.
Receiving personal care in the privacy and comfort of home can be important for recuperating, chronically or terminally ill patients or persons with disabilities. In-home care facilitates independence and functional improvement. Home health patients receive medical, nursing, and/or therapeutic treatment through a wide range of health and social services. Receiving home health care reduces unavoidable readmissions, and studies have shown that patients recovering from injury, sickness, or surgical procedures heal more quickly and with fewer complications when recovering at home versus in a medical facility.
Hospice and palliative care management connect patients and advocates. Care coordination reinforces the care continuum for homebound patients and their caregivers. Homebound patients may need assistance with daily living or medication adherence. Patients that can’t leave home because they require help from others or need a wheelchair or walker, or need special transportation or their condition restricts movement can benefit from care coordination. Homebound patients requiring, physical therapy, intermittent skilled nursing care, ongoing occupational therapy, or even speech-language pathology services can progress with TCM and CCM services.