Summary of 2002 Winning Poster

An Innovative Approach to Chronic Home Care

Dr. Phillips won the Best Poster Award 2002 at the Academy's Annual Meeting on May 9. This article summarizes his poster presentation.

In November 1996, Health Plan of Nevada (HPN) was selected to be the first second-generation "Social Health Maintenance Organization" (SHMO) demonstration program. Through the SHMO, enrolled Medicare beneficiaries receive enhanced services as determined by established criteria that are applied through a process of care coordination. HPN operates the SHMO, called the "Extended Care Program," throughout the Las Vegas metropolitan area. This program has allowed Health Plan of Nevada to provide additional services and care to those members with medical, psychological, functional and social needs not routinely covered by Medicare Plus Choice or traditional Medicare fee for service delivery models. Through the integration of planned benefits and caregivers throughout the organization, Health Plan of Nevada is a leader in the management of the chronically-ill and aged population.

Teams of RNs and Social Workers within the clinic setting assess members' needs and develop plans of care in collaboration with the primary care providers. In 1999, Ambulatory Care Management and Family Healthcare Services, Inc. developed a program to manage the chronically-ill patient in the home. They used the SHMO processes of case finding and screening to determine how members are selected for participation in the program. The overall intent of the program was to augment the care of the chronically-ill patient through an integrated approach that utilized the core principles of home health care that did not end when a skilled need was no longer present. The criteria for admission to this program were reviewed by a geriatrician to ensure that sound principles of chronic care would be implemented.

Definition of the Chronic Home Care Client:

1. All SHMO members with three or more hospitalization in the past six months related to one or more chronic illnesses.

2. SHMO member with:
   1. Monthly Foley catheter change unable to be done in provider office;
   2. Skilled wound care completed and skin healed and determination that ongoing nursing involvement is required to prevent further skin breakdown;
   3. Chronic wound care with the client or family providing care, but client cannot be followed by treatment center or provider office.

3. Frail elderly/disabled:
   1. Requiring regular physical assessment more frequently than an interval of 60 days or more (chronically disabled);
   2. Inadequate support system;
   3. Malnourished;
   4. Multiple ADL/IADL deficiencies.

To educate the home care staff, a checklist was developed to assist them with the evaluation and management of this population. This checklist included admission criteria and defined some of the chronic illnesses most frequently seen in members admitted to the hospital such as Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and Dementia. Ambulatory Care Management and Family Healthcare Services worked together to break down barriers for handing off members to each other.

During the development stage of the program, a plan to audit the success of the program was established. The general outcome anticipated was reduction of hospitalization of members identified for chronic home care needs. In March 2001, clients being served were selected as the population to review in order to determine the effectiveness of this program. From this population, all clients who had been active for at least six months (the criteria for baseline wellness described earlier) were evaluated to determine bed day utilization six months prior to admission to chronic home care as compared with six months after admission. The audit reviewed acute hospital days, sub-acute hospital days, and skilled nursing facility days. The findings were as follows:

• 91 clients were in the sample.
• In the six months prior to admission to chronic home care, this population utilized 351 hospital days, 513 sub-acute days, and 21 skilled days.
• In the six months after admission to chronic home care, this population utilized 133 hospital days, 91 sub-acute days, and 60 skilled days.
• Bed day savings for the audited population: There was a savings of $448,375.00. (Cost for acute bed day, $1,200.00; sub-acute bed day, $425.00; and skilled bed day, $225.00.)
• Cost savings for the audited population: Cost of chronic care home team = $178,600.00. Total savings = $269,775.00.

The success of a chronic home care program is dependent upon adequate financing, provider education, and acceptance. Within traditional Medicare fee-for-service dependent health care delivery models the incorporation of a physician/extender group along with the home health care agency allows for ongoing patient management. Current Federal reimbursement regulations allow for both a home health agency and physician/extender provider group to be in the home at the same time. After the home health agency discharges the patient from service, the physician/extender group is able to remain involved and continue to coordinate and provide for the ongoing needs/services of the patient. A managed care health care organization can certainly replicate the entire program. A well-developed and coordinated chronic home care program as described will truly enhance the organization's long-term viability and profitability.

In either funding model the approach to educating the provider community is similar. This includes the physicians, administrators, hospitals, home health agencies, nursing facilities, and community organizations with which the health care system works. The identification of champions within each entity of the health care system is necessary. These individuals are able to represent and promote the concepts, admission criteria, and available services that are essential to a successful chronic home care program.

Please contact Dr. Phillips regarding this article or other topics of interest at stevenp@sierrahealth.com.