Family caregivers take on the lion’s share of long-term care in the US — from managing medication to coordinating care — for their own family members. When patients and families aren’t supported with training, the day-to-day tasks can become an overwhelming burden. Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities, a recent IHI report, explored the challenges of patient safety in the home. Extensive research identified several programs providing assistance to those assuming the challenging role of caregiver. Here are just three of those innovative programs that have achieved promising results:
MedStar Medical House Call Program
This Washington, DC–area house call program provides home-based medical care and chronic disease management services for high-risk seniors with multiple chronic conditions, who are often too ill, frail, or disabled to visit health care provider offices. The program targets patients at the greatest risk of incurring high health care costs. A geriatrician completes a comprehensive at-home assessment to ascertain the patient’s clinical and psychosocial issues and potential safety hazards. The program then provides 24/7 access to an interdisciplinary care team including the geriatrician, a nurse practitioner, and a social worker, with on-call telephone coverage and frequent home visits. Clinicians make urgent house calls when needed to prevent avoidable hospitalizations, and social workers coordinate needed support services, focusing on the educational and emotional support needs of family caregivers as well.
A study found that participation in the program resulted in 9 percent fewer hospitalizations, a 20 percent reduction in emergency department visits, a 27 percent reduction in skilled nursing facility stays, and a 75 percent reduction in end-of-life hospitalizations compared to a control group. Overall, the program reduced Medicare costs by 17 percent, with a total savings of $6.1 million over two years. MedStar’s program is one of several models being evaluated in the Center for Medicare & Medicaid Innovation’s Independence at Home (IAH) demonstration program, which examines the impact of house call models on outcomes and costs.
The Care Transitions Program® (CTP®)
CTP is a four-week program in which a specially trained “transitions coach” works with patients and family caregivers to ensure a smooth transition to home from either a hospital or short-term skilled nursing facility. The transitions coach, usually a nurse or social worker, encourages patients to take a more active role in their care, providing health education and self-management strategies, performing medication reconciliation, and facilitating communication with clinicians.
The model is unique in that it uses adult learning principles to enhance patient self-management. The four “pillars” of the intervention are medication self-management, use of a patient-centered personal health record, follow-up care, and patient knowledge of “red flags.” Multiple studies provide evidence that the model is effective at reducing hospital readmissions and costs. A randomized controlled trial found a 30 percent lower 30-day readmission rate, a 26 percent lower 90-day readmission rate, and 19 percent lower per-patient costs of care after six months. More than 900 organizations in 43 states have adopted the intervention.
Community Care of North Carolina
Community Care of North Carolina (CCNC) is a statewide, community-based program for establishing access to a primary care medical home for vulnerable populations and providing those medical homes with the multidisciplinary support needed to ensure comprehensive, coordinated, high-quality care. CCNC relies on a network of primary care practices, as well as 14 nonprofit “regional networks” of physicians, nurses, pharmacists, hospitals, health departments, social service agencies, and other community organizations.
Central to these efforts are community pharmacists who partner with CCNC to provide enhanced medication management services in community settings. The services that these pharmacists provide are diverse, consisting of, for example, transitional care and behavioral health interventions.
CCNC’s overall efforts produced nearly $1 billion in costs savings between 2007 and 2010. Those who received CCNC transitional care services were 20 percent less likely to experience a readmission during the subsequent year, with benefits being greatest among patients with the highest readmission risk.
Download the Patient Safety in the Home report to learn more about the complexities of the home care setting.
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