As hospitals strive to expand access and increase capacity, more care — even for higher-acuity patients — is shifting to the post-acute space. As this occurs, patients previously cared for by post-acute providers are being cared for at home, driving demand for high-quality, in-home care.
During Becker’s 16th Annual Meeting in Chicago, a panel of healthcare leaders discussed how hospitals, health systems and home care providers are responding to these changes to provide the care that patients need in the home, without being readmitted to the hospital.
The session, titled “Home Care at the Center: Using Technology and Data to Extend Healthy Days and Prevent Hospitalizations,” was moderated by Laurel Graham, vice president, products at Homewatch CareGivers International, and featured:
• Brad Barber, senior director, care continuum, Tampa General Hospital (Fla.)
• Nancy Gillette, chief growth officer, PocketRN
• Marco Schiano, BSN, RN, owner and chief executive officer, Homewatch CareGivers of Cape May (N.J.)
Here are three key takeaways from the session:
1. Home care is an increasingly important part of the patient care ecosystem
Seismic shifts in healthcare are occurring. For example, Medicare wants all beneficiaries in managed care arrangements by 2030. The only way for health systems to deliver high-quality outcomes and control costs is to provide care at the most appropriate site of care throughout the patient journey.
Mr. Barber explained that Tampa General Hospital is leveraging its home health arm to identify what types of care patients need. The goal is to position home care as a key part of caring for patients after they are discharged from the hospital. “Home care is an extension of services beyond the episodic care provided by RNs, PTs and OTs,” he said. “It helps patients with activities of daily living.”
2. Families need help with in-home caregiving
As more care shifts into the home, families often feel overwhelmed. They are tasked with taking care of loved ones, as if they were a nurse but without the knowledge. The good news is they don’t have to go at it alone.
The GUIDE (Guiding an Improved Dementia Experience) Model is the first time Medicare has recognized home care as a covered benefit and has put dollars toward supporting family caregivers. PocketRN is a GUIDE program partner, helping fill gaps and enabling family members to speak with a clinician within 2-5 minutes.
“We built a ‘nurse-for-life’ model,” Ms. Gillette said. “Once a patient has a nurse through PocketRN, that nurse stays with the patient throughout their entire healthcare journey. We’ve seen a 30% reduction in unnecessary hospitalizations and with some partners it’s upwards of 70%. We know this model works.”
3. Technology supports human connection but doesn’t replace it
Homewatch CareGivers utilizes their proprietary technology, Homewatch Connect, to link families, patients and caregivers through a Wellness Hub. This supports virtual check-ins that complement in-home visits.
“When home care is fully integrated into the healthcare continuum, there’s additional eyes on patients,” Mr. Schiano said. “This identifies opportunities to intervene earlier and escalate to community partners to prevent ED visits and hospital readmissions.”
To secure and enable patient-centered care across the healthcare ecosystem, the panelists agreed that collaboration is essential. Success depends on breaking down silos and aligning incentives across stakeholders.
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