The Evolution of Care to the Home Setting

Healthcare industry experts predict that healthcare in the home setting will be a growing trend that is here to stay. Cleveland Clinic’s Kristine Adams, MSN, CNP, Associate Chief Nursing Officer of Care Management and Ambulatory Services, has seen a big shift in nursing trends. She and her team have been working over the past year to hire additional home care nurses. Here she answers the pressing questions.

Can you tell us more about acute care growth in a home setting?

KA: The growth in home care has been exponential over the past three to five years. Earlier this year, our nursing team went from 46 to 60 full-time home care RNs in one month to help meet demand, and we continue to hire. We are working to respond as quickly as we can.

Why is this happening?

KA: There have been big shifts in nursing and workforce economics. Our society is aging, and healthcare payers want to hold costs down. There is a high cost for institutional care. So this is really a convergence of patient needs, cost structures and our ability to provide home-based care with advancements in medical devices and technology – including the electronic medical record. Patients are discharged from the hospital for home with higher acuity needs.

Can you explain in more detail what is happening in the marketplace?

KA: The shift to home care is driven by capitation (payments used by managed care organizations to control healthcare costs) and new payer structures. Home care leaders are looking at how to care for patients with acute care needs at home, with payer’s allowing services that are outside the strict Home Care Agency Conditions of Participation (COPs) as directed by the Centers for Medicare & Medicaid Services. There are many stakeholders involved in this shift to home care that include hospitals, patients, physicians and nurses as well as payers, including Medicare/Medicaid, insurance companies and Programs of All-Inclusive Care for the Elderly (PACE) plans.

In Cleveland and our region of the country, Humana Health Insurance recently purchased Kindred at Home, a skilled nursing care home health service. We are starting to see vertical continuums being created by payers – that is, payers that own a narrow network, which limits where patients can go for any type of post-acute care. The questions are: How do these changes affect our business? And how will we incorporate into our home healthcare model the management of patients with acute care needs after discharge? For the first time in history, both payers and providers are aligned with the same goals in mind – to take optimal care of patients and achieve best-practice outcomes at a lower cost of care. Based on current data, patients who go home versus going to another post-acute site have better clinical outcomes at a lower cost of care.

Is this a good thing?

KA: Collaboration between payers and other disciplines has a lot of growth potential, and many novel ideas are being implemented, such as using the Coleman transition care model, which incorporates the use of lay navigators to assist with post-discharge needs. Lay navigators help patients navigate a complex healthcare system and arrange transportation and follow-up appointments, much like a family would advocate for a patient. The new model of care also includes use of paramedics, nurse practitioners, care coordinators, social workers and pharmacists in home settings, including skilled nursing at home, which front-loads intense therapy and nursing immediately after discharge to help patients recover at home. Cleveland Clinic is creating a sustainable model that allows for comprehensive healthcare in the home environment for patients with acute conditions and end-of-life needs. Pharmacy infusion services, home respiratory therapy, wound care therapy, hospice, home monitoring devices and virtual medical appointments (telehealth) with primary care providers in group practices give patients the ability to receive necessary acute care within their home. In addition, as needed, care management coordinates facility-based (skilled nursing and long-term acute care) physician group practices.

What is the opportunity for nurses?

KA: The new model is essentially “acute care at home.” The program provides an ideal opportunity for highly skilled nurses who wish to work independently and outside of a traditional acute care hospital. Our home care nurses administer complicated IV antibiotic regimens, provide complex care of wounds and manage many chronic conditions that are prevalent in our elderly population. Services also include educating patients and their families on how to manage their conditions. Our home care nurses use critical thinking skills and decisive judgment to meet patient needs.

What are some of the benefits of home care nursing for patients?

KA: Acute care at home allows patients to be in a familiar environment, where they are comfortable and may be less likely to have safety incidents, such as fall events, and they have the support of family and friends. Further, patients may be less susceptible to infections when at home. Thus, patents may be less likely to have adverse clinical outcomes when at home, as compared to being placed in a skilled nursing facility or remaining in an acute care hospital.

Do you have any final thoughts about the change in home care to acute care at home?

KA: Post-acute care can be challenging, but we are creating a new model that is working. A focus on acute care at home provides opportunities to decreases the risk for adverse events, and it is a patient satisfier. Thinking innovatively and leveraging available technologies expands the possibilities of how we care for our patients. As we move forward, partnering with our payers will allow for expanded bandwidth to take care of more patients as they shift out of traditional acute care earlier and into acute care at home.