1. Preliminary Data on a Care Coordination Program for Home Care Recipients.
- Author
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Dean KM, Hatfield LA, Jena AB, Cristman D, Flair M, Kator K, Nudd G, and Grabowski DC
- Subjects
- Aged, Aged, 80 and over, Caregivers economics, Caregivers education, Chronic Disease economics, Computer-Assisted Instruction economics, Computer-Assisted Instruction methods, Computer-Assisted Instruction statistics & numerical data, Continuity of Patient Care economics, Continuity of Patient Care organization & administration, Continuity of Patient Care statistics & numerical data, Cost Savings, Electronic Health Records organization & administration, Health Plan Implementation economics, Health Plan Implementation organization & administration, Health Plan Implementation statistics & numerical data, Health Status Indicators, Home Care Services economics, Hospitalization economics, Humans, Male, Medical Overuse economics, Medical Overuse prevention & control, Pilot Projects, Quality Improvement economics, Quality Improvement statistics & numerical data, Software, Chronic Disease therapy, Home Care Services organization & administration, Home Care Services statistics & numerical data, Hospitalization statistics & numerical data, Interdisciplinary Communication, Intersectoral Collaboration, Quality Improvement organization & administration
- Abstract
Home care recipients are often hospitalized for potentially avoidable reasons. A pilot program (Intervention in Home Care to Improve Health Outcomes (In-Home)) was designed to help home care providers identify acute clinical changes in condition and then manage the condition in the home and thereby avoid a costly hospitalization. Caregivers answer simple questions about the care recipient's condition during a telephone-based "clock-out" at the end of each shift. Responses are electronically captured in the agency management software that caregivers use to "clock-in," manage care, and "clock-out" on every shift. These are transmitted to the agency's care manager, who follows up on the change in condition and escalates appropriately. A description of the In-Home model is presented, and pilot data from 22 home care offices are reported. In the pilot, caregivers reported a change in condition after 2% of all shifts, representing an average of 1.9 changes per care recipient in a 6-month period. Changes in behavior and skin condition were the most frequently recorded domains. Interviews with participating caregivers and care managers suggested positive attitudes regarding the intervention; challenges included resistance to change on the part of home care staff and difficulties in applying a uniform intervention to individuals with varying needs in home care offices with varying capacities. In an ongoing randomized trial, the success of the overall program will be measured primarily according to the potential reduction in avoidable hospitalizations of home care recipients and the effect this potential reduction has on spending and healthcare outcomes., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)
- Published
- 2016
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