Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Thinking Differentlyabout Hospital
ReadmissionsLaNita Knoke RN, BS, CMCN Healthcare Strategist
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Senior Care Continuum
Family Caregiv
er
Primary Care Speciali
stsHospital
sHospice
Home Care
Home Health
Physical/Occupational
Therapy (other needs)
Rehab Family Caregiv
er
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Nutrition Medication Management
Doctor Appointmen
ts
Warning Signs
Four Areas of Focus
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Knowledge
Compliance
Meeting Basic Need
Personal Side of CareKnowledge
Compliance
Com
munic
ati
on
Com
munica
ti
on
BASIC NEEDS
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Home Instead Re-Admissions Studies
2
Livonia, MI
Richmond,VA
1
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Desired Outcome
2
1
Both Studies were designed to determine if patient compliance with discharge instructions along with monitoring of key quality outcome indicators in the home, correlated to reduced unnecessary hospital readmissions
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Study May 1, 2012 – April 1, 2013
Large for profit hospital system
1
GOAL: Reduce hospital readmissions of 16% by 1%
55 patient
pilot study
Primary diagnosis: CHF (Heart Failure)
30 DayPlan of Care
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Study July 2012 to November 2012
2 non- profit hospitals
2
GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance
30 patient
pilot study
Primary diagnosis: CHF (Heart
Failure)/COPD
30 DayPlan of Care
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Discharge Model
Example
1
2
3
4
Discharge Planners completed risk assessments on each patient
Home Instead Senior Care completed care consultations to determine patient specific home needs prior to discharge With the Discharge Planner, and based on these assessments, we determined the necessary level of care, which drove the required hours of care
Prior to discharge we worked together to created Individualized Care plans that involved the patients own goals
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
• Care Plan focused on patient-centered goals with action plans– Functional goals: drive, grocery shop, wedding, garden
• Home Instead Senior Care was present at discharge– Helped to build trust, clarify discharge instructions, and
understand the programWeek 1: one hour of
service for five visits
Week 2: one hour of
service for four visits
Week 3: one hour of
service for three visits
Week 4: one hour of
service for one or two
visits
Home Management with Patient
Employment of a Teach Back Methodology instead of a complete care approach
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Patients only remember and understand <50% of what clinicians explain to them in a hospital setting
Patient Education
Patient Engageme
nt
The discharge plans must shift
from to
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
– Medication management reconciliation from discharge
– Appointment with Primary Care Physician first week home
– Diet and Nutrition low salt
– Monitoring vital signs blood pressure, weight, fluid intake
– Warning signs red flags – red, yellow, green zones
– Organization of medical records in the home
Critical Components for Success
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
OutcomesStudy
1
23.5%
in readmission rate. Initial goal
was to drop it 1%
Reduction
97%
Upon national readmission estimates for
Medicare patients with CHF
Improvement
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
OutcomesStudy
2
96%
93%
90%
Of patients were discharged to their own homes
Of patients remained out of the hospital 30 days post discharge
Of patients remained out of the hospital 90 day post discharge
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
OutcomesIn both studies we were able to fill the discharge gap in education and compliance.
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Follow-Up Physician
Visit Assistance
Nutrition Manageme
nt
Warning Signs
Monitoring and
Notification
Medication Self
Management
Care Management with Patient
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Best Practice Results
• Ensuring nutritious Groceries are in the home, reviewing the hospital diet instructions and providing mealtime socialization
• Physician appointment within 7 days post discharge, testing and therapy follow up completed when scheduled by providing transportation and assistance
Disciplined, consistent
discharge process
Successful hospital to home
transition
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Results (Cont.)
• Teaching patients to care for themselves instead of doing the care for them
• Developing the Returning Home Program
• Focusing on initial Admission Prevention
• Medication Management needs resulted in launching Simple Meds by Home Instead
Each Home Instead Senior Care franchise office is independently owned and operated.
Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Person-centered solutions to reduce hospital readmissions