This is the final article in a six-part series exploring ways to improve the delivery of whole-person, value-based care to Medicare and Medicare Advantage populations. In this post, we cover care management strategies to improve the experience for members who receive home health care services.
You can also download our white paper Effectively Managing Medicare Populations: 6 Focus Care Areas to get more information and insights about other areas to improve for Medicare plan members.
A significant number of Medicare enrollees require one or more home health services. This may include part-time, medically necessary nursing care, physical therapy, occupational therapy, speech-language therapy, medical social services, part-time home health aide care, durable medical equipment, medical supplies for use at home, and even medications.
In 2019, there were 10,591 Medicare-certified home health agencies in the United States, and more than 7.4 million quality episodes of care were provided to more than 5.2 million beneficiaries. Of these, 31.2 percent were paid by Medicare Advantage, and 60.4 percent by Medicare Fee for Service (FFS).
Some services may not be covered by the members’ plan, but the member may need them to maintain good health. These long-term services and supports (LTSS) may include things like 24-hour at-home care, meals, homemaker services (cleaning, laundry, shopping), and custodial care or personal care to help with daily living activities (bathing, dressing, using the bathroom).
Improving outcomes and engagement among this population depends on efficient care coordination and better insight into the member’s home health environment. Read on for a discussion of technology-supported strategies that can position Medicare payers to meet these challenges.
Efficient Home Health Requires Payers to Optimize Care Coordination and Communication
Members that require care in the home need a different care management approach. Because this group of patients typically interacts with a suite of healthcare professionals and in a variety of environments, effective care coordination is essential for improving healthcare outcomes, as well as member engagement and satisfaction rates.
According to a Commonwealth Fund report, a lack of coordination between providers can increase the risk of poor outcomes for Medicare enrollees requiring home health services. This is particularly true for those who also receive LTSS.
For example, shift changes between home health aides are associated with an increased risk of hospital readmission within 30 days of discharge, the authors note. This risk alone demands a stronger approach to care coordination for this population.
Care managers can help ensure care coordination and collaboration by being the eyes and ears in the home. They need to stay updated on emerging health concerns, adverse events, safety issues, and changes in members’ conditions.
Key strategies to achieve this include:
- Implementing telemedicine, which empowers care managers to maintain communication with members receiving home care
- Using remote patient monitoring (RPM) devices, which helps care managers to better track the member’s condition and safety at home, as well as encourage members to more actively participate in their own health. Members can use RPM devices for at-home tracking of blood pressure, weight, glucose levels, heart rates, and other indicators.
- Maintaining communications with community programs assisting with things like food, custodial care, or home services
How HELIOS Helps Payers to Improve Home Health Care
Care management of patients receiving home health services means collaborating with the teams providing medical care alongside home health staff and staying attuned to and connected with community programs and services. That’s a big ask, considering that disjointed systems and information silos can prevent timely communication about a member’s emerging health needs.
A medical management platform like HELIOS helps Medicare payers break down those barriers. Critically, HELIOS keeps everyone involved in a member’s care working in the same ecosystem and from a centralized source of member data.
HELIOS enables more seamless care coordination by:
Aligning everyone involved in a member’s care. With automated updates and alerts, HELIOS helps care managers by analyzing data and creating automated flags and tasks based on intelligent analysis of patient data sources. This helps keep everyone involved in a member’s care informed on emerging conditions, needs, and events that occur so that a proactive approach can be taken.
Integrating HIPAA-compliant communications with multidisciplinary teams. Using HELIOS, care coordinators can easily communicate with multidisciplinary teams across care settings through secure, HIPAA-compliant messaging, videoconferencing, chat, and data exchange. All contacts are documented via integrated Interaction forms that automatically capture many aspects of the encounter.
Supporting transitions of care. HELIOS can play a key role in helping care teams reduce avoidable hospital admissions and unnecessary emergency department visits. When members are preparing to transition or have just transitioned to home health settings, HELIOS can be used to perform all necessary coordination activities, from planning to outreach to pre-discharge assessment to education to post-discharge care planning. This streamlines care management across the continuum and expedites home health care transitions.
HELIOS also provides capabilities that help care managers deliver a more individualized, engaging – and safer – experience for members requiring home care services:
Remote tracking of members’ vitals to alert care teams when interventions are needed. HELIOS features integrations with RPM devices (wearables and other connected devices) as well as related third-party technologies. RPM data is fed into the platform in real-time, giving care managers and clinical teams the most accurate insights to guide interventions. HELIOS can also leverage RPM insights to produce automated notification triggers for care teams when preventive or outreach measures may be needed.
Remote medication management. For members who are home-bound and may need medication management support, HELIOS provides capabilities for care managers to perform medication reconciliation including checking for medication accuracy, and assessing and addressing medication adherence. This capability is complemented by seamless integrations with leading embedded drug data systems, pharmacy networks, and medication therapy management solutions.
Customizable health education resources. Many older adults have age-related hearing or vision decline that interferes with retaining healthcare information. A startling 71 percent of adults over age 60 have difficulty with print materials, 80 percent with forms or charts, and 68 percent with interpreting numbers or doing calculations. HELIOS partners with leading educational content providers like Healthwise to support both members and caregivers in addressing health literacy issues. Care managers can select the appropriate materials, walk members through them, and share them via HELIOSvisit in seconds.
Learn More About How to Improve Medicare Population Health Management
Check out the other five posts in this series to see how to improve medication adherence and outcomes for members who need additional support and services.
- How to Improve Medication Management for Medicare Populations
- How to Improve Care for Members with Medicare Who Need Long-term Services and Supports (LTSS)
- How to Integrate Behavioral Healthcare for Medicare Members
- How to Improve Chronic Condition Care Management
- How to Better Address SDOH for Medicare Members