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Top tags: DSS Commissioner Bremby  Home Health Visit 

Qualidigm Home Health Care Consulting Team Expands

Posted By Rebecca Taylor, Monday, March 20, 2017
Melissa Gordon, RN, MBA, ACHC, a leader in the home health industry and most recently at the VNA of So. Central CT in which she held several leadership roles, has joined Qualidigm's home health team as Consulting Director, managing the strategic operations of the home health consulting division. Melissa oversees the home health consulting team and works directly with home health agencies to advise and recommend quality improvement and strategic solutions. Her 27 years' experience in the health care industry, combined with knowledge of changing home health regulations, negotiation, and customer relations, is further expanding the reach of Qualidigm's efforts to assist home health care providers in managing and reporting their quality data to circumvent potential financial liability. Charlotte Steniger, RN MSN COS-C also joins Qualidigm's home health consulting team with over 20 years' experience in nursing and nurse education. She recently served as the Dir. of Staff Development at Interim Health Care of Hartford and brings diverse expertise including OASIS, EMR platforms and efficient work flow proficiencies. "As a nurse educator, I am committed to helping our clients navigate the complex regulatory and technological requirements to facilitate success. I am excited about assisting home health agencies in defining and refining their quality and work flow approach to improving their outcomes." In addition to our dedicated and knowledgeable home health staff, home health agencies can stay ahead of compliance and the new CoP QAPI requirements by using Qualidigm's web-based software product, SMARTAUDIT®.

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Cynthia Roy to present lecture on Nonprofit Success

Posted By Rebecca Taylor, Monday, March 20, 2017
If you are one who believes that entrepreneurial business skills are not required in the nonprofit world, Cynthia Roy's attitude and accomplishments will quickly change your mind. Roy, president and CEO of Regional Hospice and Palliative Care and a member of the Association Board, will share her story and resume of work with nonprofits as part of Western Connecticut State University's Macricostas Lecture Series. Roy will present "Entrepreneurship in the Nonprofit World," in two talks on Wednesday, April 5, 2017. The first will be at 1:30 p.m. in Room 122 of White Hall on the WCSU Midtown campus, 181 White St., in Danbury and the second will be at 5:30 p.m. in Room 218 of the Classroom Building on the university's Westside campus, 43 Lake Ave. Extension in Danbury.

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DSS Commissioner Bremby Engages in Home Health Visit

Posted By Rebecca Taylor, Tuesday, March 14, 2017

Roderick Bremby, Commissioner of the CT Department of Social Services (DSS), went on a Medicaid home health visit in Hartford’s north end on March 7 to witness front-line care coordination provided by a home health aide, registered nurse and administrator.


The Commissioner participated in the experience to observe the practice of care delivery in the home first-hand provided under the state’s CT Home Care Program for Elders. This was his first home health visit as DSS Commissioner.


Susan Adams, RN, BSN, PhD and V.P. of Alliance Integration for Masonicare, planned the home health visit for the Commissioner. Both Ms. Adams and Commissioner Bremby are appointees to the Lieutenant Governor’s Healthcare Cabinet – an entity exploring options for the state to improve access and quality of care while reducing Medicaid expenditures. Home health care is recognized as the most cost-effective care setting for individuals with chronic conditions, and a place that 9 out of 10 individuals say they want to receive their healthcare.


Connecticut’s licensed home health agencies have been collaborative partners with DSS in advancing the state’s rebalancing initiative, contributing to state budget savings of $103-million annually (totaling more than $1-Billion over the past 10 years) by caring for Medicaid clients in home and community-based settings as opposed to institutionalized care.


The Commissioner observed the technology used during the home visit including the patient’s medical record on the nurse’s laptop, and the dispensing of prescribed medication from a preloaded automatic VRI medication box. The nurse assessed the patient for changes in health status and noted other health-related concerns. She then filled the VRI box with physician-prescribed medications for the following week. The nurse also discussed each of the diagnoses with the patient to enhance disease self-awareness and an understanding of the inter-relatedness of various diagnoses to overall health.

Commissioner Bremby observed the home health aide dialing out on the patient’s home phone to activate Masonicare’s Electronic Visit Verification (EVV) system to document and timestamp the specific services the home health aide provided during the home visit. It was also explained to the Commissioner that the aide would need to repeat the call in and out on the state’s Sandata’s EVV system, essentially duplicating the EVV process as a result of a new DSS single vendor mandate. The Commissioner then observed the home health visit documentation by the registered nurse and the process necessary for the care delivered to be submitted for DSS Medicaid billing.


Masonicare’s care team of Allison Breault, Interim Administrator;  Nancy Walker, RN Case Manager; and Maria Merced, home health aide, were honored to host the Commissioner and Ms. Adams on the home health visit.  The patient thanked the Commissioner for the help she receives from her home health team under the state Medicaid program so that she can remain in her own home. She explained that without the nursing and home health aide support, she could not live alone. 

Tags:  DSS Commissioner Bremby  Home Health Visit 

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How Falls Prevention in Home Health Care Supports Our Seniors and Reduces Costs

Posted By Alex Stackpole, Thursday, September 4, 2014
with Dorothy Baker, Ph.D., RN, Research Scientist
Director, CT Collaboration for Fall Prevention, Yale University School of Medicine

A common term in today’s healthcare landscape is population health, or "the health outcomes of a group of individuals, including the distribution of such outcomes within the group".[1] In other words, population health aims to improve the health of entire communities.

Helping older adults prevent debilitating and costly falls is one example of how broad-based health strategies can benefit entire communities. Because most falls happen when older adults are doing things they’ve done many times before, home health care providers are the first observers and responders to fall prevention. As healthcare at home expands its services from single-patient care to a population focus, falls prevention and education play strongly into the mix.

In a series of Connecticut-based studies that began in 1990, researchers at Yale were among the first to show that fall prevention efforts decrease the number of older adults who are admitted (or re-admitted) to hospitals as a result of falling, thereby reducing health care costs.

In 1996, the State of Connecticut Injury Data report revealed that Connecticut's most common and costly unintentional injuries were fall related. In response, the Connecticut Hospital Association, the Connecticut Association for Home Care, Inc. (now the Connecticut Association for Healthcare at Home), Gaylord Hospital, Qualidigm, Yale School of Medicine; and University of Connecticut School of Medicine proposed an interdisciplinary fall prevention effort to translate original work at Yale University into protocols that could be used in clinical and community settings. The Connecticut Collaboration for Fall Prevention (CCFP) was born.

Today, the Connecticut Collaboration for Fall Prevention reaches clinicians and the older adults they serve statewide. Working in hospitals, home care agencies, emergency medical service organizations, and health departments, they’re helping health care professionals identify characteristics that increase the chance of falling and how those risks can be reduced. Over the past seven years, the Collaboration has embedded fall prevention into the state’s health care system as well as into the daily practices of thousands of older Connecticut residents.

We chatted recently with Dorothy Baker, the Collaboration’s director, about why falls prevention is so important, and how home health organizations are working at the front lines of this effort.

Q: How does the Collaboration’s falls prevention program demonstrate the concept and goals of population health management?

A: We’re addressing a problem that’s huge for older people, their families and all who are paying taxes into our healthcare system, because the cost of falls is expensive for society.

Because most falls happen to people in their own homes, the home health care community has been extremely receptive to our program. And in any town, home care agencies are in the best position to identify the people who are most vulnerable for falls.

While falls happen most in the elderly, Yale researchers demonstrated that each individual’s health and lifestyle over their lifetime create conditions that increase (or prevent) the risk of falls when they get older. The incidence of falls is high for Medicare patients, but the factors that will contribute to falls can be high even when you are young.

So we work with physical and occupational therapists, home health nurses and home care aides to identify problems before falls happen with people of all ages.

Q: What are the conditions that increase the risk of falls, and how do you help your home health care partners address these?

A: You are never too young or too old to reduce your chance of falls. We have collaborated with home health care providers to convert our research tools into clinical tools that can cue the clinician to intervene, reduce risks and hence reduce the chance of the first or repeated falls.
A typical scenario in this country is being overweight. Risks for having difficulty in old age begin to accumulate early if one is too heavy and out of shape. This can lead to orthopedic and other health issues that commonly lead to using multiple medications. A sedentary lifestyle, dehydration, overuse of prescription drugs, hearing, vision or other sensory problems. These are all examples of risks that accumulate over a lifetime and are then compounded when one experiences the normal changes that come with age. Some problems could be prevented with intervention early in life. For example, think about the number of young people currently using electronic devices to project music directly at the eardrum at high decibel levels, or babies in their car seats subjected to music at excessive volume.  

Q: Tell us about some of the home health care organizations you’ve worked with over the past seven years. How are they implementing falls prevention programs in their communities?

A: The Collaborative has trained over 1500 home care, hospital and outpatient clinicians including nurses, rehabilitation therapists, doctors, pharmacists, and home health aides.

We began by working with 27 home care agencies in Greater Hartford region that helped us develop our protocols for fall prevention in home care. We also engaged them in providing in-service training, and speaker scripts that they could use to discuss falls prevention strategies with community groups. We helped develop local coalitions of people who understood the specific health challenges in their communities.

VNA Community Healthcare was one of the first home health care agencies to implement our program. We worked with them to do multi-factorial falls risk assessments in the 34 towns they serve from their Guilford and Hamden offices. After working for two years with residents who volunteered to participate in falls reduction assessments, the agency found that 92 percent of those participants experienced no falls upon follow up. Building on this success, VNA Community Healthcare continues to educate health professionals and family caregivers in the regions they serve.

VNA East (now part of VNA Healthcare) approached falls risk prevention from a medication perspective. They developed a relationship with the University of Connecticut School of Pharmacy. Pharmacy students were given the opportunity to home visit with the VNA staff, and thereafter worked with UConn faculty to review patients’ medication lists to identify ways to reduce polypharmacy and therby reduce the risk of falling. VNA East nurses combined the pharmacy analysis with observations of their home care patients’ behaviors and risk factors; using this information to advocate adjustments in medications with the patients’ physicians.

The physical therapy manager at Visiting Nurse and Health Services of Connecticut in Vernon worked with us to help her agency implement our program in 2009 and continues to be a falls prevention advocate in that region. Currently VNA Northwest in Bantam/Litchfield offers various opportunities for screenings and education about reducing the risks for falls across they many communities they serve.

At Visiting Nurse and Hospice of Fairfield County, occupational therapists lead Tai Chi Moving for Better Balance classes and also integrate these movements into her therapy for homebound patients, helping them improve their balance, coordination and reduce their fall risk. Students and faculty in the Physical Therapy department at Quinnipiac University are also engaged in working with older adults and researching the effects of this specific form of Tai Chi.  

Our home health care partners across the state are committed to implementing fall risk reduction programs. They gather evidence (baseline data) on the factors that contribute to falls from patients and other volunteer participants. And they measure their progress in terms of falls reduction over time. Given that falls are a leading reason for older adults to be readmitted to the hospital, these efforts are very timely and are gradually receiving more (well deserved and long overdue) recognition within the other segments of the health care system.

Q: What should people think about that can help them reduce their risk of falling?

A: We encourage people to do everything possible to gain or retain strong muscles and bones – that speaks to diet, exercise and lifestyle. When a problem develops, don’t immediately look for medications. Rather, ask yourself or your primary care provider about how your lifestyle choices may be the root cause. We need water. We need to go to the bathroom every 2-3 hours. We need exercise, healthy food and clean air. We need rest. We need to resist the advertising that encourages excesses of more sugar, salt, calories, fat, alcohol, or “junk food” and even more “stuff”, as a cluttered home increases the risk of falls.

We can also think about fall prevention seasonally. In the winter, with ice and snow, we think about concentrating to ensure we walk safely and balanced. In the summer, we emphasize hydration so the blood pressure doesn’t drop too low, but also planning regular, timed trips to the bathroom to avoid rushing—a common cause of falls. Patients who take diuretics can become dehydrated, which puts them at risk of fainting and falling, especially when it is hot.  Air conditioning is dehydrating.

We always ask people: “If you fell tonight, would you know how to get up?  And if you can’t get up, do you have a plan in place to get help?” We ask people, ‘What resources do you have to call others in a fall emergency?’

For us, the “low hanging fruit” is just helping older people stop and think about their fall risk (and what a fall injury could mean for their long-term health), and then actively engage with their primary care provider to explore preventive measures they can take.

1. Kindig D, Stoddart G. What is population health? American Journal of Public Health 2003 Mar;93(3):380–3. Retrieved 2008-10-12.

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The Top 6 Medication Risks in Home Health Care

Posted By Alex Stackpole, Friday, May 30, 2014

By Kim Durand RN, Chronic Care Program Manager, Day Kimball HomeCare

Medication management is one of the most critical services that Day Kimball HomeCare provides to our homebound patients. Whether it’s filling pillboxes or administering a prescription, approximately 10 percent of Day Kimball Home Care’s home health patients require our nurses to administer or pre-pour their medications.

Working with chronically or terminally-ill patients in their homes — especially patients with diabetes, chronic obstructive pulmonary disorder (COPD), heart failure and depression — requires our team to set, review and adapt our goals while helping patients better understand and manage their conditions.

Here are the biggest medication challenges that we encounter, and how we prevent them from turning into crises:


1. Discharge-to-home (mis)communication

Communication about (and adherence to) medication plans is one of the most complex issues for the patients we transition from inpatient facilities to the home. It’s our job to make sure that the medications patients have in their homes match what their physician, hospital or nursing home have prescribed. We do long-term medication monitoring for patients receiving services within Connecticut’s Home Care Program for Elders. Based on their doctors’ orders, we set up a medication planner that dictates what, when and how patients take their meds.

Unfortunately, in situations where there’s no long-term plan in place or families aren’t monitoring and helping manage their loved ones’ care, we see much higher rates of readmission. And while doctors set up a medication plan when the patient leaves the hospital, that plan is only a snapshot in time. The real challenge is managing changes in medication that a patient may need, based on their changing condition, within the home.

2. Interactions can = death

Because patients don’t always think about what can happen if they take over-the-counter NSAIDS (non-steroidal anti-inflammatory medications) and herbal supplements along with their prescribed meds, we ask them to show us everything they take during our home visits. Any over-the-counter medication is dangerous if it’s unintentionally taken with a similar prescription medication.

Most people are not aware that Percocet contains Tylenol, so if you also take over-the-counter Tylenol, you could be getting a dangerous dose. Seniors who have arthritis and take Coumadin should not take Aleve or aspirin, which also thin the blood.

During every visit, we check for drug interactions or duplications. We consult with the at-home patient’s physicians. And we educate patients on the hazards of deviating from their plan.

3. Where did that come from?

During our in-home visits we often discover that other specialists have prescribed medication for the patient without the knowledge of the primary physician. We also discover and correct glitches that may occur with the patient’s pharmacy.

In one home visit, we discovered that a patient was getting duplicate refills of a blood pressure-and-arrhythmia controlling beta blocker — one brand name, one generic — both coming to his home through the drug store’s auto-refill plan (a program we strongly discourage our patients from enrolling in.)

Another at-home patient had been prescribed oxycontin by her nursing home — without her primary doctor’s knowledge — before her discharge. We consulted with the doctor to determine if the oxycontin should be discontinued, maintained or increased.

We often get phone calls from patients that are unsure if they have been prescribed the right medication – “I opened my bottle and this pill looks different – I’m not sure it’s my Lasix.“ We call the pharmacy and the provider to identify the pill in question and determine if it should be in the bottle.

4. Too much or too little

For patients with cardiovascular programs and diabetes, anticoagulants and insulin pose big risks in dosing and compliance. We regularly monitor the blood levels of our homebound patients on Coumadin to make sure their INR (bleeding time) count is within a normal range.

We often see diabetes patients negotiate how much insulin they take based on how they perceive they are managing their diet. We educate them to not change their insulin levels without checking with their physician. Patients who can’t see their insulin syringe need our help to administer the drug.

5. It’s all in the timing

When a patient comes home from the hospital, they have a lot of adapting to do. They may not hear (or remember) all they were told by their doctor when they left the hospital. This is where patient education in the home really makes a difference.

A patient was told by her doctor to take her insulin every morning at 7 a.m. One morning, she woke up exhausted, took her insulin and went back to sleep, forgetting the doctor’s equally important order to always eat breakfast. When she awoke at 11 a.m., hypoglycemic and agitated, she called our nurse, who explained what was happening to her body at that moment, and why the right food at regular intervals was critical to managing her condition.

6. Communication is key

Here’s a story that reinforces why we must continue to go into our patients’ homes, monitor their medication plan and help them understand its importance. Early in my nursing career, Nitropaste was used to control chest pain. In reviewing one of my patient’s medication plans, I asked him to bring out and show me everything he took by mouth and through his skin. He said, “There’s one more medication I need to get,” then pulled out a locked box and gently extracted a tube of Nitropaste. This patient perceived that the Nitropaste was nitroglycerin and that if he put it on his chest hewould explode. The patient didn’t read the label until he went to the pharmacy for a refill. His unwarranted fear was never corrected until I reviewed his plan!

The good news? Most of our in-home patients are becoming more comfortable asking questions. They expect us to give them knowledge about the medications they’re taking and how to take them. There are times where a patient says, “My gut says something isn’t right.” Our response is always “Go with your gut!”

Communication within our health system is also critical to serving patients at home. While we’re working on the technology that will seamlessly transmit patients’ information between primary care physicians, specialists and pharmacies, Day Kimball’s Care Transitions program has already made it easier for everyone who serves our home care patients to communicate more effectively. We’re giving our health care co-partners access to home patients’ electronic medical records. And we’ve developed a standard medications form that our patients take with them to their physician appointments.



Kim Durand, RN has supported patients in her community for more than 27 years. After beginning her career in Day Kimball Hospital’s medical-surgical unit, she was loaned to its home health care division and immediately loved the hands-on nature of the work.

After receiving her chronic care management certificate from Sutter Institute four years ago, Kim helped build and launch Day Kimball HomeCare’s chronic care management program, which focuses the care on the patient and the challenges they face in self-managing their illness. An active member of the Connecticut Association for Healthcare at Home, she chairs its Clinical Supervisors’ SIG group and sits on its Future of Homecare Workgroup committee.


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Misconceptions vs. Realities of Hospice & Palliative Care

Posted By Alex Stackpole, Friday, March 7, 2014
The Connecticut Association for Healthcare at Home encourages policies that support quality end-of-life care and advance-care planning. We must ensure that both chronically and terminally ill patients and their families have access to the full range of services available to them under the Medicare and Medicaid programs.

Here’s the dilemma: Despite a rapidly aging population, Connecticut residents utilize hospice services less frequently than any other state. For those who do take advantage of hospice services, the average length of stay in hospice is only 47 days in Connecticut versus 67 days nationally—Connecticut ranks last in the country in length of stay.

How can hospice and palliative care services reduce suffering and allow people to die with dignity? We drew upon the expertise of the National Hospice and Palliative Care Organization, the Center to Advance Palliative Care, Joanne Gould Kuntz, MD, Clinical Director of Palliative Services at UCONN Health Center and Holly Bessoni-Lutz, RN, MSN, Hospice Program Director at Interim Health Care.

Here are the primary misconceptions and realities about hospice and palliative care:


Hospice care is the same as palliative care.


All hospice care is palliative care, but not all palliative care is hospice care.

Both hospice and palliative care are provided by an interdisciplinary team whose members include doctors, nurses, registered dieticians, pharmacists, and social workers. In both types of care the goal is to relieve suffering and improve quality of life for patients.

Although they share these same principles of comfort and holistic support, palliative care may be introduced much earlier in disease, ideally, at diagnosis.

Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

In comparison, hospice care is palliative care that may begin once the illness becomes life-limiting or terminal and has a prognosis of less than 6 months. When patients find that the burden of treatments aimed at prolonging life prove to be greater than the benefit, that is the time to consider and enroll in hospice. Hospice care focuses on caring, not curing.



Hospice is a place.


Hospice is a philosophy of care that happens wherever the patient calls home.

More frequently, this is in a patient’s own private residence, a nursing home, a freestanding hospice residence, an assisted living facility or a hospital. Again, hospice focuses on caring, not curing. In most cases, care is provided in the patient's home. In 2012, 41.5% of hospice patients remained in their own residence.



It’s difficult to begin the process to receive hospice. Hospice is expensive.


Hospice services are available to patients of any age, religion, race, or illness. Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs, and other managed care organizations.



Hospice means giving up.


Hospice is not“giving up.”

It is not a form of euthanasia or physician-assisted suicide.

Hospice focuses on living for however long that may be with a focus on the quality of life.

It is all about setting achievable goals and respecting wishes.

Hospice care is the model for quality, compassionate care for people facing a life-limiting or terminal illness or injury. It uses a team approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient's needs and wishes. Support is provided to the patient's loved ones as well. At the center of hospice care is the belief that each of us has the right to die pain-free and with dignity, and that our families will receive the necessary support to allow us to do so.



The patient must have cancer to begin hospice.


Non-cancer diagnoses outnumber cancer diagnoses.

63.1 percent of hospice admissions in 2012 were for non-cancer diagnoses. Today, cancer diagnoses account for less than half of all hospice admissions (36.9 percent). Currently, less than 25 percent of U.S. deaths are now caused by cancer, with the majority of deaths due to other terminal diseases. Some of the top non-cancer primary diagnoses for patients admitted to hospice in 2012 remained dementia (12.8 percent), heart disease (11.2 percent), and lung disease (8.2 percent).



To begin hospice services, the patient must be close to death.


The Medicare Hospice Benefit was established in 1983 to provide Medicare beneficiaries with access to high-quality end-of-life care. A patient is eligible for hospice care if a physician determines that the patient has six months or less to live if the terminal illness runs its normal course. Patients must be re-assessed for eligibility at regular intervals, but there is no limit on the amount of time a patient can then spend under hospice care.

The hospice benefit was established with a six-month time frame in order to develop a trusting relationship with the patient and family and help them work through the end-of-life process. During this period, hospice workers need time to develop a relationship so that the individual and their family’s physical, psychological, spiritual, and emotional concerns can be treated holistically.



Patients in hospice experience a high level of pain and discomfort before they die.


Many patients may have pain and other serious symptoms as illness progresses. Hospice staff members receive special training to care for all types of physical and emotional symptoms that cause pain, discomfort and distress. Keeping the patient comfortable and pain-free is an important part of hospice care. Hospice staff works with the patient’s physician to make sure that medication, therapies, and procedures are designed to achieve the goals outlined in the patient’s care plan. The care plan is reviewed frequently to make sure any changes and new goals are in the plan.



The patient must give up all treatments related to the terminal illness before receiving hospice care.


An interdisciplinary team and the patient’s doctor evaluate each unique situation to determine and make recommendations related to the terminal diagnosis.  Treatments such as chemotherapy, radiation therapy and physical therapy may be offered to help control symptoms and improve quality of life while receiving hospice care. Each patient is unique.  Patients are encouraged to consult their physician and hospice provider to discuss their individual situation.



The patient must have set up a legal Do Not Resuscitate (DNR) in order to prevent medical personnel from administering any artificial life support in the event his/her lung or heart functions cease.


Hospice does not discriminate its care based on a person’s advance directive (or lack thereof.) An advance directive is a legal document that enables a person to plan for and communicate their end-of-life wishes in the event that they are unable to communicate.  A goal of hospice care is to help the patient and their family understand the patient’s prognosis and align the care provided with the goals and values of the patient. This may include placing limits on certain life prolonging or sustaining therapies such as CPR and mechanical ventilation.



The patient must give up their personal physician.


Hospice works with the patient’s primary doctor, along with the hospice medical director and an interdisciplinary hospice team.

Are you or a member of your family suffering from a chronic disease or terminal medical condition? Do you believe you could benefit from palliative or hospice services? Click here to access the Connecticut Association for Healthcare at Home’s searchable list of licensed hospice, palliative care and home health care agencies.>

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The Value of Telemonitoring

Posted By Alex Stackpole, CT Association for Healthcare at Home, Friday, March 7, 2014

How Telemonitoring Technology is Improving Quality, Saving Lives and Conserving Dollars


Telemonitoring offers security and peace of mind to the families of those receiving health care in their homes. It compliments and enhances the face-to-face care that home health nurses continue to provide. Telemonitoring offers an early warning system that helps physicians and home health care providers intervene before symptom warnings become crises, make changes to the patient’s care plan, and prevent re-hospitalization. And it’s conserving dollars that allow our state’s home health care agencies to serve more patients.

Recently, VNA Healthcare, UCONN School of Nursing and the UCONN Center on Aging completed a study published in Home Health Care Management & Practice that tracked outcomes of heart failure patients who were monitored via telehealth in their homes. The research team found that telemonitoring and self-care education significantly reduced these patients' hospital readmission rates by 50 percent compared to a control group. The patients also reported improved quality of life and a greater ability to manage their health.

Telemonitoring by Connecticut’s home health care agencies are enabling the state to serve more of aging residents in their homes. According Beka Apostolidis, cardiac care supervisor for VNA Healthcare, in 2013, telehealth services provided to VNA Healthcare patients saved the organization 690 home visits, which translates into approximately $70,000 in Medicare and Medicaid dollars that can be utilized to treat additional patients.

Telemonitoring recently saved the life of one of VNA Healthcare’s clients. Home health nurses, used to speaking with the homebound patient suffering from hypertension, had come to know her normal ‘baseline’ voice. One morning, the patient’s nurse checked the patient’s telemonitor and noticed that her blood pressure had dropped dramatically. The nurse also noted that the patient sounded weak, speaking in a soft voice.

A care supervisor called the patient’s daughter, who went to her mother’s home to assess the situation. Meanwhile, the nurse called the patient’s doctor, who advised the home health care team to temporarily halt the patient’s blood pressure medications. After the patient’s daughter reported that her mother was having bouts of diarrhea and was experiencing confusion, the patient was taken to the emergency department, where she was re–hydrated and released.

Over the next few days, the agency’s visiting and telemonitor nurses kept tabs on the patient through in-person visits and telemonitor checks. In consultation with her physician, they adapted dosing of her blood pressure medications, which helped normalize the patient’s blood pressure, preventing additional emergency care visits and hospitalizations.

In-home visits, seven days-per-week telemonitoring, physician consultations and family involvement enhanced the healthcare this patient was able to receive at home. In addition, continuous monitoring of her vital signs helped the patient improve and better manage her daily health routine.

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How to Reduce Hospital Readmissions: A Q&A with Barbara Katz

Posted By Alex Stackpole, Friday, March 7, 2014
A recent study by Brigham & Women’s Hospital published in the British Medical Journal looked at patients readmitted within 30 days for possibly avoidable causes. The researchers found that infection and heart failure accounted for 21 to 34 percent of the total readmissions. They concluded that care after hospital discharge should focus not only on the primary diagnosis, but also on related complications.

What are some of the ways we can save Connecticut’s healthcare delivery system money, and improve outcomes, by preventing patients from being re-admitted to the hospital after their surgery or treatment? How does home health care enter into the equation?

For answers, we turned to Barbara Katz, Director of Clinical Program Development at VNA Community Healthcare, which serves 34 Connecticut cities and towns from offices in Hamden and Guilford. As recipient of the Connecticut Association for Healthcare at Home’s 2013 Judith A. Hriceniak Award for Excellence in Nursing Leadership, Barbara leverages her nursing background and strong business acumen to support clinicians and home health care professionals as they improve hospital-to-home care transitions.

Q: Why is reducing hospital readmissions critical to improving the quality of care and outcomes for patients?

A: Readmissions are quite expensive and are contributing to growing and unsustainable medical costs. Cardiologist Harlan M. Krumholz, MD, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) and director of the Robert Wood Johnson Clinical Scholars Program at Yale has researched the after-effects of people’s admission to hospitals.

While Dr. Krumholz studied first-time admissions, we also know that re-admissions expose people to the same stressors: Patients can become physically deconditioned, losing the strength they need to perform daily activities. Elderly patients can become delirious. Medications can get changed or mixed up.


Q: What does the Affordable Care Act (ACA) ask hospitals and home health agencies to do to avoid readmissions?

A: First and foremost, the ACA imposes severe financial penalties on hospitals for readmissions. This is the driver of much of the readmission reduction work being done. In each state, Medicare Quality Improvement Organizations have been set up to reduce readmissions. Here in Connecticut, Qualidigm is working collaboratively with hospitals and post-acute healthcare providers to reduce readmissions. A number of Medicare innovation grants are focused on preventing readmissions. Yale New Haven hospital has a grant for a care transitions program called Co-Starr that was funded in this way.

The ACA is also providing funds to test new models of financing such as post-acute bundling of payments. This is based on the theory that giving post-acute health care providers and hospitals one payment will induce them to work together more effectively, which will lower costs. If Medicare forces everyone to adopt value-based purchasing and pay-for-performance models, that will also help reduce re-admissions.


Q: How have home health agencies always sought to reduce hospital readmissions?

A: Home health care nurses have always taught patients self-care skills. We recommend home modifications to reduce falls and injuries that reduce hospitalization. We act as the patient’s advocate with the medical care system.

We help patients with Chronic Obstructive Pulmonary Disorder (COPD) learn how to breathe better. We teach heart patients how to monitor and check their weight. These measures are just two examples of how we help keep our patients from being re-admitted to the hospital.

Physical and occupational therapy provided in the home, including customized exercise programs to help patients function at their optimal level, reduces falls and helps reduce unnecessary hospital re-admissions. Occupational therapy, which is often overlooked, has played a vital role in helping patients improve their movement to more safely perform daily living activities.


Q: What are hospitals doing now to reduce readmissions?

A: Interdisciplinary teamwork is becoming an integral part of the hospital-to-home care continuum. We’re beginning to remove the silos through frequent communication.

Our agency belongs to a multi-disciplinary care transitions group at Yale New Haven Hospital. We discuss how to communicate across settings and what each entity in the continuum needs to know to avoid future readmissions. We also work together to put in place best practices and offer education to our patients.

There’s now a lot better transfer of information between hospitals and home health care entities. For example, Yale New Haven Hospital’s EPIC data capture system provides data to patients, their families and home care providers during the first 48 hours after the patient’s discharge. Patients can also get access to the system to monitor their admissions, which also serves as a readmission reduction tool.

Hospitals are measuring readmissions and feeding back the data to the home care agencies they refer to. At some point in the future, referrals may be dependent on results, i.e. lower readmissions.

Q: How are home health care agencies using clinical best practices to reduce readmissions?

A: Home health care best practices include things like front-loading home visits, ensuring that patients see their physician within a week of discharge to adjust medications and modify the treatment plan if that’s needed, medication reconciliation. We use telemonitoring to help patients learn self-management. Telemedicine also provides an early warning system that helps us identify patients who are physically decompensating due to their heart condition.

Some agencies, such as ours, are training staff in patient engagement, health literacy and motivational interviewing to deal with patients’ adherence to their care plan, which is a major problem in readmissions.

Home health care agencies are also breaking down communications barriers with other post-acute providers with strategies such as pre-discharge liaison visits, regular readmission case reviews and nursing home diversion strategies. Some agencies are using APRNs to see the sickest and most high-risk patients after their discharge from the hospital.


Q: What still needs to be done to reduce hospital readmissions?

A: Primary care doctors — the one key stakeholder group that is not yet active in hospital readmission collaboratives, but can make all the difference in avoiding readmissions —need to become much more engaged.

Meanwhile, home health care agencies need to better understand the factors that are driving readmissions and the ways to address them. Home health care agencies must become much more sophisticated in the use of data, the tools and the techniques of process improvement. This usually means changing traditional work processes, and, in some cases, work structures, such as changing from a geographic model to a specialty model of service.

Home health care agencies must strengthen their liaisons with other post-acute healthcare providers, including skilled nursing and assisted living facilities. Our VNA does liaison visits to the skilled clinical facilities in our area. We engage with the social worker in each facility. We help the patient’s family understand what’s realistic, what can be done in the home and what can’t. We do regular re-admission case reviews: what worked, what didn’t what could be done better.

Finally, we health care professionals need to shift our brains to think of ourselves as partners with patients, not directors of their care. We must learn to use health literacy, motivational interviewing, health coaching and other sophisticated techniques to engage patients in their self-care. This interdisciplinary teamwork needs to become an integral part of how we work with patients who have complex needs.

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