The Future of Home Health Care Workshop Summary (2015) / Chapter Skim
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8 Making Connections
8 Making Connections
Pages 105-116
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From page 105... ...
In one panel at the workshop, three speakers spoke about different connections that are needed to integrate home health care into the broader health care environment: connecting to the overall health care system, connecting to social services, and connecting data. Connecting to the LargeR Health Care Ecosystem Barbara Gage The Brookings Institution Changes in the broader health ecosystem affect home health significantly, said Gage, especially as organizations focus on the triple aim of the Patient Protection and Affordable Care Act of 2010 (ACA)
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From page 106... ...
Shared savings from the achievement of quality goals are available to several categories of providers, and incentives to coordinate care are in place, she said. Finally, she said, accountable care organizations (ACOs)
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From page 107... ...
"It isn't just one unique service." Although some home health care patients have complex care needs, they probably do not need 24-hour nursing or they would have been discharged to a long-term care hospital, a rehabilitation hospital, or a skilled nursing facility, Gage said. On a scale from 1 to 100, home health patients have the highest mean self-care score, about 60, when they start home health care, she said, which is some 15 points higher than that for patients in skilled nursing facilities (Gage et al., 2012)
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From page 108... ...
In many areas, she said, "standardized information is being moved into either the quality programs or the payment programs, or both." The strengths of home health that Gage believes will help shape its future are the proven programs that home health agencies often provide, including both home health care and hospice; the broad array of services that they provide, including nursing, therapy, social work, and aide services; 2 ImprovingMedicare Post-Acute Care Transformation (IMPACT) Act of 2014, Public Law 113-185, 113th Cong., 2nd sess.
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From page 109... ...
At the Altarum Institute's Center for Elder Care and Advanced Illness, Joanne Lynn has continued to develop a locally anchored, comprehensive model called MediCaring accountable care communities (ACCs) , which would create some of the needed connections, she said.
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From page 110... ...
, which anchors the project in the community and works toward achieving sustainability. Building such care plans and convincing policy makers of their value would enable the kinds of documents that health and social service providers could more easily follow on the basis of an understanding of "which services work, which are cost-effective, which are timely, and when they need to be adjusted," Montgomery said.
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From page 111... ...
The United States is quite different from the rest of the developed nations in the share of aggregate social services spending that goes to these health-related supports, which is very low, she said. A package of waivers of existing Medicare rules would be necessary to pilot test the MediCaring ACC program, Montgomery said, among which are • Waiving the Medicare rule limiting skilled nursing or therapy ser vices delivery in the home to those who are homebound, • Allowing nurse practitioners to authorize home health care or hos pice services in states where that is permitted, and • Allowing ACOs or other entities to enroll only frail elders and al low the geographic concentration of services.
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From page 112... ...
Numerous workshop participants pointed out that their home health agency used a data system different from the ones used by other providers in their networks. According to O'Malley, the creation of a shared information platform is therefore a significant challenge that will require the following: • A compelling business case, • The use of health information exchanges or other exchange mecha nisms to connect with others, • Low-cost ways to access the exchanges, • Adoption of common data management standards to transmit data reliably, • Standardized information that is meaningful to providers and oth ers who can use it to monitor system performance, and • Effective channels for two-way communication between service providers and patients and families.
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From page 113... ...
5 is added to the CDA file and reconsolidated by SEE. Upon discharge from the nursing facility, an updated document is sent to home health and the primary care physician.
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From page 114... ...
This model represents a solution to the challenge of sharing essential health information across different sites to facilitate the level of care coordination needed by patients with complex medical conditions, O'Malley said. If home health agencies participate in this shared information exchange between health care and community-based service providers, it provides them with the opportunity to play a number of new roles, in addition to the role of service provider, O'Malley said.
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From page 115... ...
Act of 20146 will require reporting on standardized measures that will give a much closer look at patient function and a broader view of service provider capabilities, as well as greater accountability across post-acute care settings.7 Gage said that the act's quality metrics are all basic information that home health agencies already monitor and collect. Even with more standardized post-acute care metrics, coordination of these services with hospitals is likely to continue to pose challenges.
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From page 116... ...
Part of the organization around MediCaring ACCs involves bringing the emergency medical service providers to the table, Allen noted. Just by working more closely together locally, improvements in how services are linked can be made.
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