Enhancing Care Communication

Home Care Connect™ provides two-way communication and remote monitoring of home-based patients

If the results of a 2016 pilot program are any indication, a home-care program using consumer electronics (e.g., tablets) with two-way video and remote monitoring should result in a more satisfied and better-informed patient, and reduced hospital readmissions and ER visits.

Home Care Connect™ is a program of Trinity Health At Home, the national home health care ministry of Trinity Health. It makes use of Plano, Texas-based Vivify Health’s continual care technologies to connect home-based individuals with Trinity Health At Home caregivers, who will remotely monitor their well-being.

Based in Livonia, Mich., Trinity Health serves communities in 22 states with 93 hospitals, as well as 120 continuing care programs, which include PACE (Program of All-Inclusive Care for the Elderly), senior living facilities, and home care and hospice services.

The initial “go live” for Home Care Connect was set for April in Trinity Health’s southeast Michigan communities. After that, the program will expand to Trinity Health At Home’s other agencies in seven states – Michigan, Indiana, Iowa, Illinois, California, Maryland and Ohio.

Virtual visits
“Trinity Health At Home’s Home Care Connect using Vivify Health technology enhances our care program by providing a two-way video communication component in addition to data collection,” explains Erin Denholm, president and CEO, Trinity Health At Home.

Participants will receive a kit that includes a 4G-enabled tablet configured with voice and text instructions. Directions walk users through steps for monitoring and reporting on their current wellness status, receiving immediate feedback, and taking part in virtual visits and patient education programs. Other wireless devices connected to the tablet, such as a scale, blood pressure monitor and pulse monitor, will automatically collect patient data regarding weight, blood pressure and other relevant measurements. Clinicians will review the data regularly, noting changes, and proactively intervening as needed.

“Patients may also spontaneously activate a virtual visit any number of times to assure care needs are being met,” says Denholm. “Sometimes, the patient may simply have questions and need reassurance from their care team about concerns.

“We are happy to communicate with our patients as they need us. In the rare circumstances in which patients may contact us in excess, we will take this as an indication that there is an unmet need. We will alert our social work teams to evaluate the patient’s needs, if needed.”

Instant connection
Home Care Connect may eventually serve up to 80 percent of Trinity Health At Home’s clients, including those with specialized care services, such as diabetes care, cardiac care, wound care, infusion therapy and joint rehabilitation, says Denholm. “The program will benefit most elderly populations at risk for chronic illnesses in the communities we serve. [It will] enable us to make in-the-moment interventions to meet patients’ urgent needs, thus preventing unnecessary ER visits and potential hospital readmissions.

“Home Care Connect, using Vivify Health’s communication features, will enable a patient and nurse to connect instantly,” she continues. “The care team can evaluate and make care decisions. This program makes the home care team even more valuable. Patients are happy to stay exactly where they want to be – home. Patients in our pilot Home Care Connect program reported a greater sense of satisfaction knowing that their care team has access to their vital information.

“The results of the pilot program are extremely encouraging,” says Denholm. “Zero patients were readmitted to the hospital 30 days after discharge. One hundred percent of patients found using remote monitoring technology helpful, and 100 percent of patients have a better understanding of their health condition after using the program’s technology. We look forward to an extremely positive impact on our patients in communities throughout the seven states we serve.”

People-centered care
Denholm believes that remote monitoring and virtual visits will enhance Trinity Health At Home’s commitment to people-centered home-based care.

“Virtual care and remote monitoring is an extraordinarily important component of our people-centered care. Home Care Connect enables truly individualized care and empowers patients to stay where they want to be. For some patients, this program’s connectivity with their care team may mean fewer in-person visits are necessary, as they may connect with their care team with two-way video or by phone. For some patients, this program’s connectivity may empower us to proactively intervene as necessary and prevent an ER visit by prompting an in-person home care visit by the care team.

“Trinity Health At Home has a new vision and strategy of getting better and getting different – required to continue our mission of providing the best care to all those who need it in the communities we serve,” she continues. “Due to anticipated changes in the care model, we do believe the clinical team will carry a higher caseload while making fewer in-person visits with remote care, [but] coupled with home visits, [Home Care Connect] actually provides a sense of more care to patients.

“Home-based services with integrated virtual care are really no longer defined by an acute care stay,” says Denholm. “The healthcare world – and how health systems and physicians get paid for care – has changed significantly over the last several years. Identifying high-risk and rising-risk patients with high predictability for unplanned ER visits can trigger the use of remote monitoring without an admission to home care. The impact on total cost of care and savings is changing practice patterns.

“Healthcare providers are now recognizing the extraordinarily important role home-based services can provide. With the ability to proactively monitor home care patients and provide in-the-moment interventions, Home Care Connect makes it possible for someone to stay where they are most comfortable – the sacred place they call home.”


By the numbers

Emergency department visits among adults aged 65 and over

Data from the National Hospital Ambulatory Medical Care Survey shows:

  • During 2012–2013, adults aged 65 and over had an emergency department (ED) visit rate of 12 per 100 persons for injury and 36 per 100 persons for illness.
  • Both injury and illness visit rates increased with age. Adults aged 85 and over had the highest visit rates (25 per 100 persons for injury and 57 per 100 persons for illness), and adults aged 65–74 had the lowest visit rates (9 per 100 persons for injury and 29 per 100 persons for illness).
  • Among adults aged 65 and over, women had a higher ED visit rate for injury (14 per 100 women) compared with men (10 per 100 men). There was no difference between women and men in the visit rate for illness.
  • The percentage of injury visits resulting in hospital admission (17 percent) was lower than for illness visits (32 percent) among adults aged 65 and over. The same pattern held for critical care admissions (2 percent compared with 5 percent).
  • Imaging was ordered at 75 percent of injury visits among adults aged 65 and over, which was higher than for illness visits (63 percent).

Source: Emergency Department Visits for Injury and Illness Among Adults Aged 65 and Over: United States, 2012–2013, Centers for Disease Control and Prevention, NCHS Data Brief No. 272, February 2017 (https://www.cdc.gov/nchs/products/databriefs/db272.htm)


Avoidable hospitalizations drop for long-term care facility residents

Avoidable hospitalizations have dropped dramatically over the last several years, according to the Centers for Medicare and Medicaid Services.

As reported in a January CMS blog post, “In 2015, Medicare fee-for-service (FFS) beneficiaries living in long-term care facilities had a total of 352,000 hospitalizations. Of this number, Medicare beneficiaries eligible for full Medicaid benefits living in long-term care facilities (LTC Duals) accounted for 270,000 hospitalizations. And, almost a third (approximately 80,000) of these hospitalizations were caused by six potentially avoidable conditions: bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, chronic obstructive pulmonary disease or asthma, and skin ulcers.”

In its analysis, CMS discovered a 31 percent decrease in hospitalization rates for those six potentially avoidable conditions for LTC Duals between 2010 and 2015. With improvements in rates of potentially avoidable hospitalizations in all 50 states, “dually-eligible long-term care facility residents avoided 133,000 hospitalizations over the past five years,” notes CMS.

The agency attributes this decrease to joint efforts among Medicare and Medicaid, federal government agencies, states, patient organizations, and others working through provisions in the Affordable Care Act.

Some of these efforts include:

  • An initiative launched in 2011 by the Medicare-Medicaid Coordination Office, CMS Innovation Center, and other partners to reduce avoidable hospitalizations among nursing facility residents in seven sites across the country.
  • Initiatives such as the Hospital Readmission Reduction Program, aimed at reducing excess readmissions.
  • Efforts to align care with quality through Accountable Care Organizations, the Bundled Payments for Care Improvement models, and other delivery system reforms.

According to CMS, “This success shows that a sustained commitment to smarter spending across the entire health care system can yield dramatic results and improve the lives of vulnerable Americans.”

To view the full CMS blog post, visit https://blog.cms.gov/2017/01/17/data-brief-sharp-reduction-in-avoidable-hospitalizations-among-long-term-care-facility-residents/.