According to the Centers for Medicare and Medicaid Services (CMS), 75 percent of hospital re-admissions are preventable with adequate home care. Preventing re-admissions could save more than $25 billion in health care expenditures over the next ten years.
Most re-admissions result from patients having difficulty complying with medical directions once they are discharged. Patients may fail to follow up with primary care physicians, misunderstand their conditions or symptoms, or improperly follow medication regimens. Synchronized care can remove barriers to patient recovery, drastically reducing the number of readmissions. For those who don’t qualify for full home care, wrap-around care with home assessment offers five crucial services to promote faster, more efficient recovery:
1. Medical Reconciliation
In synchronized care models, a qualified medical professional assesses the contents of patients’ cupboards, so to speak. Medical professionals ensure that the medications a patient has on hand match the medications prescribed by doctors. They remove unnecessary or outdated medications from the home, and they help patients and caregivers comply with medication schedules.
2. Coordinating with In-Home and Community Support Systems
Effective patient recovery requires a strong support system at home. Patients who live alone rarely have such support systems, and they benefit greatly from regular check-ins with medical professionals who help oversee their self-treatment.
For patients who do live with other people – immediate family members or extended family or “ohana”, for example – medical professionals educate others in the home about what they can do to help the patient recover. Friends and family members learn about the patient’s medical, dietary, and general health needs, and they learn how to assist the patient in meeting the key health-related goals. For example, the significant other of a diabetic person can learn how to help provide the patient with a low-sugar diet; the children of a person with a complicated medication schedule can help ensure the patient never forgets to take their medication.
An in-home/community-based support system also ensures that patients follow up with primary care physicians and seek medical attention when necessary.
3. Assessing the Home Environment
With wrap-around care, medical professionals make intensive assessments of a person’s home and address any environmental barriers to health. For example: does the house need to be drastically cleaned to reduce allergies and asthma? Does an aging person need to install rails in the shower to prevent falls? Does the person have a mode of transportation to and from doctor’s appointments? Does the person know what kind of food to keep in the house? Thorough home assessment from a care provider who knows a patient’s history and health risks makes a dramatic difference for preventing chronic illness complications.
4. Assessing the Risk for Slips, Trips and Falls
Synchronized team members will also evaluate the home situation and potential risk issues related to slips, trips and falls. Are there issues of strength and mobility? Are there physical risk factors such as stairs, loose carpets or clutter? Is the solution based on establishing a routine exercise program to maintain balance and strength? Or does the home require home modifications such as grab bars, built- in ramps or decluttering? Synchronized care can also educate home caregivers on fall safety programs and their role in assisting in creation of a safe home environment.
5. Emergency Room Diversions
When patients and caregivers are properly educated about recovery, they know what signs and symptoms to look out for. They know when to call a nurse, when to visit the urgent care center, and when to head to the Emergency Room.
With wrap-around care that extends into the home, medical professionals can offer in-home education. They can hang fliers and charts in the house that remind patients about how to best take care of themselves and what do when they need medical advice or attention.
Patients tend to be happier living at home, rather than in health care facilities, and in-home education initiatives incentive them to take care of themselves to and allow for an aging-well in place, or explore options for the next level of care that is appropriate to meet their care needs.
In these ways, synchronized care addresses barriers that may prevent patients from recovering properly in the home. Better in-home recovery means fewer hospital re-admissions; and fewer hospital re-admissions means lower health care expenditures for everyone involved.