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Courtney Davis, MHAHOME CARE + Program Manager
January 14, 2015
Centers for Medicare and Medicaid Health Care Innovation Award
• Improved Health
• Improved Care
• Reducing Costs through improvement
Home Care + is supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Mission and VisionMISSIONTo ensure optimal health and care of each Home Care + participant to
successfully remain at home. • Person-centered coordination across care settings• Appropriate support and care at the appropriate time• Actively engaging the Home Care + participant and family
VISIONHome Care + will be the leader in community-based care coordination.
• Person-Centered Community-based Care Coordination• Relationship-building• Engaging participant/family in care and decision making• Collaborative Problem Solving• Team Approach
– Client/Family– Home Care Consultant (RN or LPN)– Home Care Specialists – “Trusted Source”– Home Care Specialist Trainer– Physician– Discharge Planners and Others– CLTC Case Manager
• Negotiated Plan of Care• Chronic Disease Management Training for Personal Care Aides
HOME CARE + Innovations
HOME CARE + Model
Home Care +
Participant
Home Care Consultant
Home Care Specialists
PCPA Trainer
Personal Health Record
On-Call Support
Team Approach• Internal• External
PCPAs is the hub
HOME CARE +Key Areas to Support Self-Care
• Relationship with participant/family• Medications Management• Follow-up care with physicians • Chronic disease education and warning signs
that a condition is worsening• Use of Personal Health Record
Home Care Specialist Certification
• 12 modules• Enhance knowledge of chronic conditions• Increase the ability of the home care worker to
recognize a change in condition that could prevent the need for an acute care transfer
• Upon the completion of each 1-hour module, a certificate of completion will be provided
• Completing 12 modules will result in a Home Care Specialists Certificate
HCS Training Modules1. Intro to the Role of Home Care Specialist2. Congestive Heart Failure3. Dehydration4. Pneumonia5. Incontinence and Urinary Tract Infections 6. Heart Attack7. Chronic Obstructive Pulmonary Disease8. Hypertension9. Stroke10. Diabetes11. Mental Status Changes/Dementia12. The Final Phase of Life
Lessons Learned
• Careful selection of Home Care Consultant• Impact of Trust• Relationships are critical
Preliminary Outcome Data
Jan-13
Jan-13
Feb-13
Mar-13
Mar-13
Apr-13
May-13
Jun-13
Jun-13Jul-1
3
Aug-13
Aug-13
Sep-13
Oct-13
Nov-13
Nov-13
Dec-13Jan
-14
Feb-14
Feb-14
Mar-14
Apr-14
Apr-14
May-14
$0.00
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
$30,000.00
$35,000.00
$40,000.00
Estimated cost of ER visits as reported by HOME CARE + Par-ticipants at admission and after 6 months in the program
(Estimated cost of ER $1402 times number of reported visits)
Self Report Pre ER costLinear (Self Report Pre ER cost)Self Report Post ER costLinear (Self Report Post ER cost)
- $130,386.00
-$918.21/pp
Preliminary Outcome Data
$0.00
$50,000.00
$100,000.00
$150,000.00
$200,000.00
$250,000.00
$300,000.00
$350,000.00
Estimated cost of Hospital visits as reported by Home Care + participants at admission and after 6 months in the program.
(Estimated cost per hospital visit $19,256 times number of reported visits)
Self report Pre Hosp cost
Linear (Self report Pre Hosp cost)
Self report post Hosp costs
Linear (Self report post Hosp costs)
- $1,039,824.00
-$7,322.70/pp
Stories from the Field
• Mr. Clark• Ms. James• Ms. Cook
Where is HOME CARE + ?
Advantages of HOME CARE + Model
• Point of Contact in the community• Home Care Consultant in Provider Network• Established relationship with participant/family and Personal
Care Aide• Engaged participant/family• Personal Care Aide in participant’s home 2-5 times/week
(“eyes and ears”)• Personal Care Aide trained on “red flags” of signs and
symptoms of worsening condition that could lead to avoidable ER visit
