Patients seeking care for chronic conditions often are heavy consumers of health care because of their frequent admissions to hospitals, but home-health companies are pushing to reduce those admissions — and the resulting costs — through technology, care transition programs and the possibilities of coordinated care.
"New Jersey (is) one of the higher-cost states for Medicare beneficiaries and other populations, and I think the neat thing is home care has an opportunity to be a solution … we're able to create value for Medicare and Medicaid," said Dr. Steve Landers, CEO of VNA Health Group, the Red Bank-based consortium of New Jersey chapters of the Visiting Nurses Association. "The state is paying more attention to how we keep vulnerable populations healthy at home."
Susan Grinkevich has been tracking hospital readmission rates as a nurse administrator for Holy Redeemer Homecare and Hospice New Jersey North, in Elizabeth, for more than a decade — long before that statistic became a top metric for quality measurement and health care reform.
"What's come to light in the recent year or two is all of the research and evidence-based practice that has been done on transitions, going from one health care provider to the next," Grinkevich said. "And many patients go from the hospital to home."
That's why Grinkevich has been leading a transition team, with Trinitas Regional Medical Center and Jewish Family Services of Central Jersey, to ease patients with heart failure or chronic obstructive pulmonary disease back home and into managing their conditions. The team is funded by a $100,000 grant from the Grotta Fund for Senior Care.
The transition team includes two part-time nurses who check whether recently discharged home-care patients have seen their primary-care physician for a follow-up appointment, are adhering to proper medications and have proper medical equipment at home to maintain independence.
"Home care can continue to provide the assessment and interventions to continue that adjustment out of the hospital and that path to patient self-management," Grinkevich said. "They can live their lives and not have to worry about being sick all the time."
Landers, who joined the VNA from the Cleveland Clinic at the beginning of June, said the organization is focusing on expanding its use of technology to monitor patients with chronic issues at home before hospitalization is required, and keeping detailed notes and records on tablets the visiting nurses carry with them. Landers said the new equipment helps the nurses use appropriate resources to ensure patients are maintaining their health outside of the hospital.
Another longtime New Jersey-based home-health care company, Bayada Home Health Care, is expanding to meet the growing need for transitioning patients to the home. Mark Baiada, founder and president of the Moorestown-based company, said it now has 40 service offices in the state, as well as a presence in more than 20 other states.
Bayada has grown 15 percent annually over the course of its 37-year history, and has expanded beyond caring primarily for seniors. "We've expanded into high-tech pediatric care, which is a third of our total work," Baiada said, adding the service is one of seven differentiated types of home-health care the company offers. "We try to coordinate them all, because the average person could move from one to the other."
Post-acute care — part of Bayada's offerings — is a key ingredient for an accountable-care organization, and Baiada is wasting no time trying to become the preferred provider with which hospitals can contract.
"We're working with hospitals and hospital systems that are forming ACOs. They've come to the realization they're going to be on the hook for post-acute care, including rehospitalization," Baiada said. "That's where all the money is. Home care compared to hospital care is small, so the whole system wants to be more efficient. We're trying to replace hospital readmissions with home care, and it's working."
Grinkevich agrees, and said of the 22 patients enrolled in the Holy Redeemer transition team program, 86 percent were able to remain at home after discharge. Nationally, readmission rates generally are between 20 percent and 30 percent.
Grinkevich said she's working with Healthcare Quality Strategies Inc. and providers in Middlesex, Union and Monmouth counties to translate the pilot program into a Medicare demonstration of a so-called community-based care transition program, which would expand coverage beyond the city of Elizabeth.
Landers said the VNA Health Group is considering its options within coordinated care groups, acting as the hub for an ACO, aligning as a service provider within an ACO or serving as the coordinating care arm for an organization.
Baiada also sees the traditional role of care coordination making companies like his the ideal leaders for the new care models.
"We're moving up from being an unknown part of (ACOs) to being central to it," Baiada said.
"We're also on the other side. We don't want people going to the hospital in the first place," Baiada said, adding that keeping patients with chronic issues healthy at home keeps them off "the medical treadmill."
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