Home Care Captures the Spirit of the Medical Home
By Richard Scott
August 14, 2012
Like much of the other movements in our modern, reform-era healthcare, the medical home model and accountable care organizations are steeped in elements of patient-centered care.
One of the trends defining this nationwide push is the practice of care management, which currently is expanding into a wide range of settings throughout the healthcare system.
Among those settings is home care. To gain insight into new models that are pushing the boundaries of traditional care management and elevating patient outcomes, Medical Home Today sat down with Janet Coulter, RN, MSN, CCM, a nurse case manager with WorkStar Health Services, a managed care organization based in Ohio.
Medical Home Today: Can you describe the type of medical home you’re involved with?
Janet Coulter: In this model (patient-centered care), the patient is the center of care and an active part of the healthcare team. The case manager coordinates all aspects of care and facilitates communication, partnerships, and care coordination between the patient and healthcare professionals. Episodic healthcare is replaced with coordinated care and the patient's home is the healthcare setting/medical home.
Care is coordinated across all elements of the healthcare system (hospital, home health agency, subspecialty care, nursing home, skilled facility, home) and includes all stages of life (acute care, chronic care, preventive services, and end-of-life care). Patients actively participate in their own health and well-being, making decisions and providing feedback regarding quality of care they receive. This model provides well coordinated care with home as the health care setting or medical home.
MHT: You mentioned this is a return to an old model. What do you mean by that?
JC: This is a similar model used by home health care nurses for many years.
MHT: How do case managers effect change in this model?
JC: The case manager has the role of facilitating communication with the patient/patient’s family and primary physician, collaborating with other healthcare providers, coordinating care, and organizing home care of the patient in an ongoing process.
MHT: Are you seeing that patients buy in to the program?
JC: Yes. This model empowers the patient to have control of their healthcare and gain what services they may or may not want.
MHT: What types of outcomes are you seeing in general?
JC: This model of care has led to some pretty significant outcomes across the board. Among them are:
- Empowerment of patients.
- Decreased patient anxiety and stress.
- More efficient and effective healthcare.
- Decreased hospital readmission.
- Smooth transitions of care.
- Containment of costs.
- Fewer unwarranted trips to the ED.
- Decreased medication errors.
- Increased client/client’s family healthcare education
MHT: Can you offer an example of a successful interaction with a patient?
JC: Sure. Let’s call the patient “Mary E.” Well, Mary E. is an 84-year-old widow who lives at home alone. Her only child lives three hours away. She was diagnosed with rheumatoid arthritis after an acute flare up. She desperately wants to continue to live independently in her home of over 70 years.
Mary has several physicians (including a primary care physician, rheumatoid specialist, podiatrist, internal medicine, ophthalmologist, and endocrinologist) who all prescribe medications and each of whom has a plan of care. Mary is very compliant and strives to follow each physician’s directions, but, perhaps not surprisingly, it became overwhelming and confusing.
By implementing patient-centered care, the case manager was able to empower and guide Mary to be a more active participant in her health care through several means: become more knowledgeable about her medications (side effects, brand/generic names); coordinate her medications between the mail-in pharmacy and her local pharmacy with the help of her local pharmacist; coordinate appointments with physicians as several physicians were located in a neighboring community; coordinate transportation to physician appointments; and make educated decisions about her healthcare.
Mary continues to live happily at home alone, adjusting to changes she had to make because of the limitations of rheumatoid arthritis, and coordinating her care from her home with the assistance of her case manager. Several hospital admissions/ED visits have been avoided and medication reconciliation has prevented several medication errors.