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04.21.16

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Care Coordination and Home Care for Older Adults

Care Coordination and Home Care for Older Adults

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.

However, older adults needing only non-clinical home care and assistance, such as help with eating, dressing, walking, meal preparation, and housekeeping. Medicare does not cover these types of services. Before choosing to receive care at home, chronically ill patients must consider many factors including pain management needs, isolation, transportation, and home safety and maintenance. Without coverage for supportive, preventive and care management services, serious exacerbations of underlying illness will result in costly hospitalizations and emergency care.
 
Chronic Care Management (CCM) and Transitional Care Management (TCM) can prove vital to older adults and their caregivers that choose home care, and have gaps in coverage for home health benefits. CCM and TCM Care Managers work alongside physicians and other healthcare professionals to outline and deliver at home care planning for chronic, complex conditions requiring around the clock care coordination. Inadequate home care coordination and planning can result in poor patient outcomes, unnecessary hospitalizations, poor star ratings, and lower reimbursement.
 
Older patients with complex and chronic conditions are increasingly choosing home care. As a result, there is a greater need for CCM and TCM services to support agencies and providers with comprehensive care planning, electronic documentation, and record keeping and timely coordination of services. Managing complex conditions in home care requires frontline Care Managers experienced in chronic disease management, care coordination strategies, and patient engagement for lifestyle and behavioral changes. Adding dedicated Care Managers to coordinate and track non-clinical home care needs can not only improve management of patient health outcomes but also make making receiving care at home more accessible.

About the Author

Joseph F. West, ScD

Joseph F. West, ScD

Joseph F. West, ScD, is a population health and data analytics leader with over 10 years of research and enterprise consulting experience. He is a recognized leader in the development of outcomes-based healthcare. Joseph has served as Chief Population Health Officer, Senior Epidemiologist, Program Director, and Adjunct Assistant Professor. As a consultant and content creator, his current work focuses on population health management (PHM), health information technology (HIT), care coordination innovation, and healthcare risk management.

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