A number of folks from Support For Home, where we provide non-clinical home care and geriatric care management services, recently attended a presentation by Cheri A. Lattimer, RN, BSN, who is the Executive Director of the Case Management Society of America. The title of her talk was, “Where is Your Future in Accountable Care Organizations?” It was a spot on discussion.
Among the critical points made by Ms. Lattimer is how care will be delivered under health care reform, including:
- Multidisciplinary care teams across sites of service
- Care Transitions
- Improved coordination of care for dual eligibles (i.e., Medicare, Medicaid)
These points reflect the criticality of multiple service providers working together to improve care, in multiple settings. Let us look at a few examples:
- A senior with dementia is admitted to the hospital for pneumonia. That patient is a prime candidate for delirium, in the hospital, with the outcome being very problematic for the patient. We know that having a family or professional caregiver with the patient in the hospital dramatically improves the probability of a positive outcome.
- A non-compliant (diet) diabetic patient is discharged from the hospital, with good numbers. With no or inadequate family support at home, the probability of a return to the hospital within 30 days is greatly increased, unless dietary management is provided by a reputable non-clinical home care agency, working with a good home health agency, to support dietary compliance.
- A senior discharged from a hospital following hip replacement is a very likely candidate for early readmission, without professionally trained caregivers who can support the transition back to the home setting.
There are many examples – real stories – that could be provided in this context. Clinical and non-clinical health care providers have to work together in new and creative ways if health care reform and Medicare reform is to have any chance of success.
Below is an adaptation and expansion of a graphic from Ms. Lattimer, stressing the criticality of the role of the hospital Case Manager:
What is missing from this picture is lines of communication among all of the various providers. The Case Manager begins (prior to and at hospital discharge) at the center of the universe, alongside the patient. Once the patient leaves the hospital, however, communication among home care, pharmacy, PCP, insurance, … must be in real-time and direct, in order for the patient’s care – and outcomes – to be maximized and readmissions minimized.
We all have a lot of work to do – and a lot of re-learning to eliminate “that’s the way it has always been done” from our thinking. Wish us luck. 🙂
Best wishes. Bert