Home Instead Senior Care was able to significantly reduce (4%) hospital readmissions among seniors in the Richmond, VA market. Partnering with HCA Henrico Doctors Hospital, the 11-month program included 61 patients who were admitted to the hospital (primary diagnosis: congestive heart failure) and then received an average of 103 hours of companionship services from Home Instead Senior Care.
2. What we do
Companion care, home helper and
personal care services
• Light housekeeping
• Meal Preparation/Nutrition/Grocery shopping
• Transportation
• Medication Reminders/Follow-up Dr.’s appointments
• Home safety evaluations/Red Flags
• Personal care – assistance with bathing and dressing
8. Pilot Study
Partner with large for-profit hospital system – HCA
Henrico Doctors Hospital
– May 1, 2012 through March 31, 2013
– 61 patient pilot study (48 completed)
– Primary diagnosis – Congestive Heart Failure
– 30 Day plan of care
GOAL: Reduce hospital readmissions by 1%
9. Care Management with Patient
Nutrition Medication
Management
Doctor
Appointments
Warning
Signs
10. • Risk assessment done on each patient who had heart failure based
upon their risk factors
• Categorized patients level of care
Risk Factors and Assessment
Limited
Moderate
Significant
Decided on hours of care based upon the assessment
Care plan created on all patients upon discharge
11. Outcome
• Hospital readmission rate overall dropped from16.5% to
12.5%
• Total hours based on patient need and additional care
available (Average - 103 hours per patient for 30 days)
• Approximately $2,000 per patient
• Able to fill gap in education and compliance
12. Outcome
• Events/Speaking Engagements
• Currently servicing 7 clients who participated in the pilot
• Finalizing the abstract and white paper
• Opportunities nationally with other hospital systems
14. Test and GoalsPilot Study
• July 2012 to November 2012 with 2 non-profit hospitals
– Hospital #1 part of the tenth largest national healthcare system in the U.S.
and is a 304 bed acute care community hospital
– Hospital #2 is a 220 bed medical/surgical hospital
• 30 Patient Study
• Primary diagnosis – CHF (Heart Failure) and COPD
• 30 Day plan of care (Day 1 is discharge from hospital)
• GOAL: Reduce unnecessary hospital readmissions within the first
30 days of discharge while improving patient self-reliance
15. Model
• Main focus on patient-centered goals with action plans
– Functional goals: drive, grocery shop, wedding, garden
• A care consultation to be done in the hospital with Home
Instead Senior Care, to determine patient specific needs
– Build trust, clarify discharge instructions, understand the program
• Base 30 day plan
Week 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
16. Teach-Back Show-Me Method
• Patients remember and understand <50% of
• what clinicians explain to them
• The model must shift from patient education to patient
engagement
• Critical components for success:
Medication management
(reconciliation from discharge)
Appointment with Primary Care Physician (first week home)
Diet (salt)
Monitoring vital signs (blood pressure, weight, fluid intake)
Warning signs (red flags – red, yellow, green zones)
Organization of medical records in the home
18. Outcome
• Solidified us as solution to Re-Admissions
• Solidified us as a provider in the hospitals
• Invited to speak as a community leader
• Invited to participate in Integrated Care Opportunity
19. Operations
• Staffing:
• 2 CAREGivers at 7 daysx10 hours
• Supervision: RN recommended but not required
• CAREGiverTraining:
• Coaching not Doing
• Redflags, blood pressure, weight, fluid intake
• Diet/Salt – importance of reading labels
• Doctor appointments and Medication Reconciliation
