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.
Moving a patient from a hospital to their home or care facility in a community setting is a delicate process. Patients, family members or caregivers can receive confusing recommendations, a laundry list of medications, and conflicting instructions regarding follow-up care. If they are not included in planning or provided with clear “next steps” there can be significant gaps in post-discharge care. As a result, patients will most likely return to the hospital, and often times with more complications than before.
One in five Medicare enrollees is readmitted to the hospital, ED or urgent care within 30 days of discharge, and nearly three-quarters of these readmissions are preventable. Miscommunication, lack of provider accountability, and inadequately prepared or shared care plan leads to ineffective care transition. Consequently, the patient is vulnerable to adverse events. Under the Patient Protection and Affordable Care Act, along with shifts to value-based care and shared risk models, providers and healthcare systems now face financial penalties due to unnecessary readmissions.
Social conditions and chronic disease are related. Overcoming social factors can be a challenge for the two-thirds of Medicare beneficiaries with two or more chronic conditions. Many of these patients struggle with housing concerns, lack of access to transportation, inadequate nutrition, and job loss. Some are isolated from family and face fragmented care.
Unfortunately, healthcare providers have traditionally had little success in addressing the social, environmental and cultural factors that affect health. Patients can feel ashamed and not share information during a typical doctor's visit or even while in the hospital. Most healthcare providers are ill-prepared to assist patients with difficult issues such as food access, substandard housing, family conflicts, social isolation, or in some cases childcare or adult caregiving issues. Having a plan of action to address these factors can prevent disability and illness.
It’s important to remember that patients with chronic conditions can still enjoy life. While chronic diseases can affect a patient’s ability to perform some important daily activities, this doesn’t have to completely restrict social engagement and their enjoyment of family and friends. Enhanced and ongoing communication with doctors, a focus on medication compliance, and patient health education offered by chronic care management (CCM) can provide immediate and long-term benefits. CCM and Transitional Care Management (TCM) can help doctors improve patient health-related quality of life, and boost the number of healthy physical and mental days.
Provider approved discussions on self-care activities like exercise can improve pain scores, and eliminate fatigue and sleep problems. Exercise can even reduce the risk for falls, a common cause of nonfatal injuries in seniors. Emphasizing to patients the need for social engagement to eliminate a sense of isolation and loneliness can stave-off depression. Many doctors and their patients don’t consider exercise and social engagement as prevention or treatment for chronic conditions which may provide as much benefit as surgery or medication. Not to mention the potential for fewer side effects or harm.