As health care continues to move outside of hospitals, strategies to improve safety and outcomes in other settings — including the home — are beginning to show results. The recent IHI report, Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities, took a broad look at the current home care landscape. Two programs in particular demonstrate the value of conducting comprehensive health and safety assessments and addressing needs through a combination of health care and community services.
Community Aging in Place: Advancing Better Living for Elders (CAPABLE) Program
CAPABLE is a home-based intervention that aims to keep low-income older adults functioning as independently as possible in their own homes to enhance their capacity to “age in place.” Participants in the program, which was recently studied as part of a demonstration project funded by the Center for Medicare and Medicaid Innovation (CMMI), receive home-based patient-centered nursing care, occupational therapy, and handyman services. Home repairs and modifications, such as installation of stair railings, grab bars, improved lighting, assistive devices, and raised toilet seats, allow participants to navigate their homes more easily and safely.
The intervention is designed to reduce health care utilization by improving medication management, home safety, and functional status while decreasing isolation, depression, and fall risk. Several studies found that the model is effective at reducing nursing home and hospital admissions, improving functioning and quality of life, and reducing health care costs.
Results of the demonstration project showed that 75 percent of participants improved their performance of activities of daily living after completing the program. A more recent evaluation noted that the program was associated with reduced total Medicare expenditures. CAPABLE has received funding to expand the program to three cities in Michigan as part of Michigan Medicaid’s pilot program to deliver home and community-based services to help keep nursing home-eligible adults in the community.
Mobile Integrated Community Health Program
In 2014, the Queen Anne’s County, Maryland, Department of Emergency Services (EMS) launched an innovative program to improve outcomes among the county’s most vulnerable, medically complex residents. The first of its kind in Maryland, the Mobile Integrated Community (MICH) Program targets high-risk patients who frequently call 9-1-1 and provides intervention-based health care services, home safety assessments, and referrals to community services. A field team (paramedic, nurse practitioner, and behavioral health professional) performs a comprehensive, in-home assessment that examines the patient’s physical, social, and behavioral health. As relevant, a pharmacist conducts a televisit for medication management. The team uses evidence-based tools to assess safety risk, including the Hendrich II Fall Risk Model and the Physical Environment Assessment Tool (PEAT).
According to MICH leadership, the program has served a total of 116 patients and has achieved successful outcomes, reducing calls to 9-1-1 by 23 percent and avoiding an estimated 132 emergency department visits over a 12-month period. By leveraging EMS workforce and infrastructure, the program represents an efficient approach to improving outcomes among a high-risk population.
Community paramedicine (the use of paramedics beyond their customary emergency transport roles) is a model of community-based health care that is emerging as a national trend. In Arizona, several pilot programs that focus on fire service-based community paramedicine are indicative of models that show promise for improving health outcomes among medically underserved populations through home-based assessment and care, patient education, home safety assessments, and referrals to social services. EMS providers in Arizona have partnered with the state’s health department to develop a formal “treat and refer” program; the initiative leads national efforts in the area of reimbursement by offering cost recovery for EMS agencies providing community paramedicine services.
These examples show how collaboration between health care providers, social service organizations, and communities can go a long way toward improving safety in the home, enabling seniors and those with complex health care needs to avoid the hospital or other higher-level care settings.