Mission Statement:

Enhancing the lives of aging adults and their families.

Home Instead

What we doCompanion 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

Nutrition Medication Management

Doctor Appointmen

ts

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, 2013– 61 patient pilot study (48 completed)– Primary diagnosis – Congestive Heart Failure– 30 Day plan of care

GOAL: Reduce hospital readmissions by 1%

Care Management with Patient

Nutrition Medication Management

Doctor Appointmen

ts

Warning Signs

• 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

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

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

Detroit, MI

Re-Admissions Study

Test and Goals

Pilot 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

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 planWeek 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

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

Outcomes

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

Operations

• Staffing: • 2 CAREGivers at 7 daysx10 hours• Supervision: RN recommended but not required

• CAREGiver Training: • Coaching not Doing• Redflags, blood pressure, weight, fluid

intake• Diet/Salt – importance of reading labels• Doctor appointments and Medication

Reconciliation

Returning Home

Thank You!