Mission Statement:
Enhancing the lives of aging adults
and their families.
Home Instead
What we do
Companion care, home helper and
personal care services
• Light housekeeping
• Meal Preparation/Nutrition/Grocer...
Nutrition Medication
Management
Doctor
Appointments
Warning
Signs
Four Areas of Focus
Senior Care Continuum
Personal Side of Care
Knowledge Compliance Meeting Basic Need
Richmond, VA
Hospital Re-Admissions Study
Pilot Study
Partner with large for-profit hospital system – HCA
Henrico Doctors Hospital
– May 1, 2012 through March 31, 2...
Care Management with Patient
Nutrition Medication
Management
Doctor
Appointments
Warning
Signs
• Risk assessment done on each patient who had heart failure based
upon their risk factors
• Categorized patients level of...
Outcome
• Hospital readmission rate overall dropped from16.5% to
12.5%
• Total hours based on patient need and additional ...
Outcome
• Events/Speaking Engagements
• Currently servicing 7 clients who participated in the pilot
• Finalizing the abstr...
Detroit, MI
Re-Admissions Study
Test and GoalsPilot Study
• July 2012 to November 2012 with 2 non-profit hospitals
– Hospital #1 part of the tenth largest...
Model
• Main focus on patient-centered goals with action plans
– Functional goals: drive, grocery shop, wedding, garden
• ...
Teach-Back Show-Me Method
• Patients remember and understand <50% of
• what clinicians explain to them
• The model must sh...
Outcomes
Outcome
• Solidified us as solution to Re-Admissions
• Solidified us as a provider in the hospitals
• Invited to speak as ...
Operations
• Staffing:
• 2 CAREGivers at 7 daysx10 hours
• Supervision: RN recommended but not required
• CAREGiverTrainin...
Returning Home
ThankYou!
Preventing Hospital Readmissions - Home Instead Senior Care
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Preventing Hospital Readmissions - Home Instead Senior Care

Home Instead Senior Care was able to significantly reduce (4%) hospital readmissions among seniors in the Richmond, VA market. Partnering with HCA Henrico Doctors Hospital, the 11-month program included 61 patients who were admitted to the hospital (primary diagnosis: congestive heart failure) and then received an average of 103 hours of companionship services from Home Instead Senior Care.
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Preventing Hospital Readmissions - Home Instead Senior Care

  • 1. Mission Statement: Enhancing the lives of aging adults and their families. Home Instead
  • 2. What we do Companion care, home helper and personal care services • Light housekeeping • Meal Preparation/Nutrition/Grocery shopping • Transportation • Medication Reminders/Follow-up Dr.’s appointments • Home safety evaluations/Red Flags • Personal care – assistance with bathing and dressing
  • 3. Nutrition Medication Management Doctor Appointments Warning Signs Four Areas of Focus
  • 4. Senior Care Continuum
  • 5. Personal Side of Care Knowledge Compliance Meeting Basic Need
  • 6. Richmond, VA Hospital Re-Admissions Study
  • 7. Pilot Study Partner with large for-profit hospital system – HCA Henrico Doctors Hospital – May 1, 2012 through March 31, 2013 – 61 patient pilot study (48 completed) – Primary diagnosis – Congestive Heart Failure – 30 Day plan of care GOAL: Reduce hospital readmissions by 1%
  • 8. Care Management with Patient Nutrition Medication Management Doctor Appointments Warning Signs
  • 9. • Risk assessment done on each patient who had heart failure based upon their risk factors • Categorized patients level of care Risk Factors and Assessment Limited Moderate Significant Decided on hours of care based upon the assessment Care plan created on all patients upon discharge
  • 10. Outcome • Hospital readmission rate overall dropped from16.5% to 12.5% • Total hours based on patient need and additional care available (Average - 103 hours per patient for 30 days) • Approximately $2,000 per patient • Able to fill gap in education and compliance
  • 11. Outcome • Events/Speaking Engagements • Currently servicing 7 clients who participated in the pilot • Finalizing the abstract and white paper • Opportunities nationally with other hospital systems
  • 12. Detroit, MI Re-Admissions Study
  • 13. Test and GoalsPilot Study • July 2012 to November 2012 with 2 non-profit hospitals – Hospital #1 part of the tenth largest national healthcare system in the U.S. and is a 304 bed acute care community hospital – Hospital #2 is a 220 bed medical/surgical hospital • 30 Patient Study • Primary diagnosis – CHF (Heart Failure) and COPD • 30 Day plan of care (Day 1 is discharge from hospital) • GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance
  • 14. Model • Main focus on patient-centered goals with action plans – Functional goals: drive, grocery shop, wedding, garden • A care consultation to be done in the hospital with Home Instead Senior Care, to determine patient specific needs – Build trust, clarify discharge instructions, understand the program • Base 30 day plan Week 1: one hour of service for five visits Week 2: one hour of service for four visits Week 3: one hour of service for three visits Week 4: one hour of service for one or two visits
  • 15. Teach-Back Show-Me Method • Patients remember and understand <50% of • what clinicians explain to them • The model must shift from patient education to patient engagement • Critical components for success:  Medication management (reconciliation from discharge)  Appointment with Primary Care Physician (first week home)  Diet (salt)  Monitoring vital signs (blood pressure, weight, fluid intake)  Warning signs (red flags – red, yellow, green zones)  Organization of medical records in the home
  • 16. Outcomes
  • 17. Outcome • Solidified us as solution to Re-Admissions • Solidified us as a provider in the hospitals • Invited to speak as a community leader • Invited to participate in Integrated Care Opportunity
  • 18. Operations • Staffing: • 2 CAREGivers at 7 daysx10 hours • Supervision: RN recommended but not required • CAREGiverTraining: • Coaching not Doing • Redflags, blood pressure, weight, fluid intake • Diet/Salt – importance of reading labels • Doctor appointments and Medication Reconciliation
  • 19. Returning Home
  • 20. ThankYou!

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