As the patient gets released from the hospital their need for medical care doesn’t always come to an end. Whether they are going home or to a skilled nursing facility, orders for follow-on medical care and social services are often sent along too. These follow-on care services can include such things as nursing care, physical therapy, and patient education. Depending on what is in the orders, the patient may need to meet with a health aide, physical therapist, nurse educator, social worker, or some other kind of practitioner. Each patient’s need for follow-on care is unique.
No single practitioner or practice is likely to be able to deliver everything the patient’s follow-on care plan requires. Without some sort of formal cooperation among providers, the patient might receive suboptimal care and end up in relapse or need to be readmitted to the hospital. Something beyond the collective skill and experience of these practitioners is needed to ensure that every member of this medical team can work together and deliver the best care while containing costs. That something is home care coordination.
Home Care Coordination Supports Value-based Outcomes
With home based care delivery, better care coordination can be possible and patients feel satisfied to receive the care at the comfort of their home. Each practitioner delivers their services, while still communicating freely so that each one can know the patient’s current status and when is the best time to deliver their particular service. Duplication of treatments, services, and appointments is eliminated. Scheduling conflicts are avoided and the overall flow of care is streamlined.
For ACOs operating under the CMS value-based care model home care coordination is a cornerstone strategy. Direct contracting agencies taking care of the risk-based population, organizations participating in hospital-at-home will find home care coordination valuable and cost-effective. When care coordination is successfully implemented, the care given is delivered more safely and efficiently. The result is more effective medical treatment and overall care management.
Communication Is Key for Successful Home Care Coordination
To successfully implement care coordination, all the people involved in the patient’s care including doctors, nurses, specialists, social workers, caregivers, the patient themself, etc., must be able to freely and easily share information about every aspect of the patient’s health and be on the same page.
The information needs to be shared in a way that is standardized so that it can be trusted as accurate and understood to be complete. Everyone needs to be able to see all of the patient’s orders, appointments, and chart notes. This will allow each practitioner to understand the overall picture of the patient’s health and treatments. This will also enable each practitioner to schedule and, if needed, adjust the other ancillary services needed across the care continuum. For example, a physical therapist will want to see notes from an aide documenting exercise sessions between PT sessions or a diabetes educator will want to see glucose readings to determine the effectiveness of a patient’s daily insulin dosing. The information shared needs to reflect what treatment options and other supports are available to the patient. This is not just to keep the services provided within the limits of their coverage, but also to alert the practitioners to all the options that are available to the patient.
Home Care Coordination Solutions Brings Care Teams Together
Home care coordination doesn’t automatically occur on its own. It requires active management of the medical/non-medical care team and the flow of services that they provide. This can be particularly difficult when the team is made up of multiple,and independent providers. One cannot assume that the providers are already linked in a way that supports care coordination. It is highly unlikely that they will share an EHR system or any communications system.
How do you bridge this gap? By implementing a better care coordination solution that also supports non-clinical needs of patients. A home care coordination solution puts a shared platform for communication in place for all the caregivers on the team to use. This platform can be accessed and records updated remotely from the patient’s home or where they are. It reflects updates to the patient’s record in near-real-time. The most robust home care coordination solution also supports the use of telemedicine, housecalls and remote patient monitoring. The dispatching of providers whether on-demand or scheduled visits brings greater visibility into the patients health and their surroundings at home to observe the SDOH data.
Beyond enabling open communication, a single care coordination solution provides support for several specific aspects of effective home based care delivery. Additionally, a home care coordination solution provides the data security needed to ensure patient privacy. It does this by creating a single, HIPAA-compliant point of entry to the patient’s records for the care providers to use which can be integrated from an EHR.
Final thoughts,
Why bother with home care coordination? Because, as the patient returns home from the hospital or acute care facility, care coordination will ensure the care received is effective, safe, and delivered efficiently. Most importantly, home care coordination helps avoid the dollar and human costs associated with readmission and recurrence. Our RainbowCare Coordination Solution will give your network health care providers the connectivity and communications platform needed by your patients to have a smooth transition home from the hospital or acute care setting. By enabling care coordination and follow up the patient will experience better health and avoid unnecessary and expensive readmissions.