Spotlight on Transitions, Care Coordination

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)

Spotlight on Care Coordination and Transitions for Home HealthMedicare’s focus on care transitions represents a terrific opportunity for home care agencies to demonstrate their effectiveness at preventing readmissions. A recent “Health Affairs” article noted that beneficiaries in Medicare fee-for-service programs see an average of five physicians. Clearly, care coordination must be a laser focus for this group.

Health Affairs’ 2010-11 survey of Medicare Advantage plans examined the population health management practices of 72 Medicare Advantage Organizations (MAOs) with enrollment greater than 10,000 beneficiaries. The goal was to delve into the programs that MAOs use to meet the needs of their populations.

The survey found that:

  • Wellness promotion is a key component of population health management, including smoking cessation, wellness discounts, and exercise and nutrition programs.
  • Disease- and case-management programs are an essential part of caring for those with multiple chronic conditions, including addressing the psychosocial needs of the patients.
  • For the frail elderly, integrated care and case management both lead to beneficial outcomes, particularly when they identify clinical issues, functional status and quality of life.

When asked about preventing readmissions, many MAOs reported that medication reconciliation, coordination of home health services, house calls and post-discharge home visits significantly lower readmission rates.

With agency clinicians already providing many of these services, home care agencies are uniquely positioned to support CMS’s efforts, improve care for large numbers of elderly patients and prevent readmissions.

To that end, it’s critical to promote your expertise in care coordination and your track record with successful transitions—you want to be seen by hospitals and other providers in your community as having the technology, such as home health software, and expertise in these areas. Focus on services that can improve care, especially for the frail elderly and those with multiple chronic conditions.

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