How Home Health Can Improve Patient Outcomes for Medicare Beneficiaries Post-Discharge
Home Health can Improve Patient Outcomes for Medicare Beneficiaries Post-Discharge. Medicare beneficiaries are individuals who are at least 65 years of age or recipients of Social Security Disability Insurance for more than two years. The beneficiaries can be some of the most vulnerable in US communities and face an array of health challenges.
The population is growing as well. MedPAC reports there is a projected increase, “from 54 million beneficiaries today to over 80 million beneficiaries by 2030” (Medicare Payments Advisory Council 2015). Health systems and providers will need to incorporate patient-centered strategies, such as home health partnerships, to improve this ever-growing population’s health outcomes.
Medicare and Hospitalizations
Main Reasons for Hospitalizations in the Medicare Population
In 2018, inpatient stays for those of 65-74 years of age were mainly due to septicemia, osteoarthritis, heart failure, acute myocardial infarction, cardiac dysrhythmias, chronic obstructive pulmonary disease and bronchiectasis, pneumonia (except that caused by tuberculosis), spondylopathies/spondyloarthropathy (including infective), acute and unspecified renal failure, and cerebral infarction (“Most Common Diagnoses In Hospital Inpatient Stays – HCUP Fast Stats” 2021).
Main causes of hospitalizations attributed to individuals aged 75 years of age and older were from the same conditions septicemia, heart failure, pneumonia (except that caused by tuberculosis), cardiac dysrhythmias, osteoarthritis, urinary tract infections, acute and unspecified renal failure, cerebral infarction, fracture of the neck of the femur (hip), initial encounter, acute myocardial infarction (“Most Common Diagnoses In Hospital Inpatient Stays – HCUP Fast Stats” 2021).
Additionally, many acute care events that result in hospitalization of the Medicare population stem from chronic disease such as diabetes and hypertension (Centers for Medicare and Medicaid Services 2012).
Discharge Planning and Medicare Patients
The day a hospital admits a patient, the discharge planning begins. A comprehensive discharge plan for a Medicare-covered patient must ensure they receive the necessary post-hospital care. The goal is to facilitate a successful recovery and reduce unplanned hospital readmissions. The planner must help make specific necessary arrangements to another care setting as well as give the patient and/or their support system pertinent recovery information such as prescriptions for new medication treatments and rehabilitation (Young and Kroth 2018, 87).
Transitions of Care
When a patient is transferred from the hospital to another care setting, things can go wrong. For instance, patients may not understand a new medication regimen. Or, they may not clearly understand the doctor’s instructions. Issues such as these can result in a follow-up hospitalization. Hospital readmissions reflect low quality in care and fragmentation within healthcare delivery; (the Medicare program exposed these trends with the implementation of the Hospital Readmission Reduction Program).
Even when hospitalists successfully deploy patient-centered communication and analysis, patients undergoing discharge (as well as their families) have much on their minds–things may get lost in translation. This can especially happen in an unfamiliar setting—(such as a convalescent institution)—without the constant support and presence of loved ones. Care team staff is subject to missing vital transitional care information as well; unsuccessful hand-offs do occur.
Home Health and Improved Patient Outcomes Post-Discharge
In-home care can bridge the current gaps in the discharge and transition of care process as well as improve post-hospitalization outcomes for the high-risk Medicare population. As an alternative to institutionalized care, home health allows the patient to heal in the comfort of their own—which studies have shown to facilitate better patient outcomes. The article Home Care Program Reduces Hospital Readmissions in Patients With Congestive Heart Failure and Improves Other Associated Indicators of Health showed that home care boosted medication adherence and was overall, “a preferable cost-effective route to care for these patients” ultimately decreasing unplanned hospital readmissions (Maliakkal and Sun 2014).
Does Medicare Cover Home Health?
Medicare covers eligible services—such as the ones listed below—under the Parts A and B:
- Part-time Skilled Nursing
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Part-timeHome Health Aide/Personal Care
A home health care agency, in most cases, coordinates the services that a doctor orders for their patient. Home health services may also include medical supplies for use at home, such as durable medical equipment (“Home Health Services Coverage” 2021).
Growth in Home Health Services for the Growing Medicare Population
The rapidly growing aging population has created a demand for home healthcare services. From 2010 to 2030, 10,000 individuals each day will turn 65 (Young and Kroth 2018, 377). More consumers will need hospital care, which in turn will demand successful post-discharge outcomes to conserve resources. Home health care is an excellent way to improve patient outcomes for the Medicare population.
Centers for Medicare and Medicaid Services. 2012. “Chronic Conditions Among Medicare Beneficiaries”. Baltimore, MD: Centers for Medicare and Medicaid Services. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf.
“Home Health Services Coverage”. 2021. Medicare. https://www.medicare.gov/coverage/home-health-services
Maliakkal, Anto V., and Amy Z. Sun. 2014. “Home Care Program Reduces Hospital Readmissions In Patients With Congestive Heart Failure And Improves Other Associated Indicators Of Health”. Home Health Care Management & Practice 26 (4): 191-197. doi:10.1177/1084822314527763.
Medicare Payments Advisory Council. 2015. “The Next Generation Of Medicare Beneficiaries”. Washington, D.C.: The Medicare Payments Advisory Council. http://www.medpac.gov/docs/default-source/reports/chapter-2-the-next-generation-of-medicare-beneficiaries-june-2015-report-.pdf.
“Most Common Diagnoses In Hospital Inpatient Stays – HCUP Fast Stats”. 2021. Healthcare Cost And Utilization Project. https://www.hcup-us.ahrq.gov/faststats/NationalDiagnosesServlet?year1=2018&characteristic1=0&included1=1&year2=2018&characteristic2=25&included2=0&expansionInfoState=hide&dataTablesState=hide&definitionsState=hide&exportState=hide.
Young, Kristina M, and Philip J Kroth. 2018. Sultz & Young’s Health Care USA. 9th ed. Burlington: Jones and Bartlett Learning, LLC.