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JAMA Viewpoint on Home Health Strikes a Chord

Posted 10/2/2013 Categories: healthcare reform, primary care, EMR, research, chronic care

A highly regarded colleague of mine, Dr. Steven Landers, who is the Visiting Nurse Association Health Group President & CEO, published a piece in the Journal of the American Medical Association (JAMA) last week that struck a chord with me, and I need to address three key points he made that I believe are critical to improving the healthcare system in America.

  1. The quantity and quality of research regarding Medicare’s home health program are limited.
  2. To further improve coordination, health information technology policy should address integration of home health records with medical records.
  3. Advanced practice nurses and physician assistants have made important contributions to primary care, and these professionals should be permitted to certify and oversee home health.

First, while it is true that research regarding Medicare’s home health program are limited, I don’t believe we should wait for CMS to conduct it. The leaders in our industry, Amedisys included, must begin to support objective research into the program’s efficacy and areas for improvement. Only then will we be able to prove the value of the skilled care we provide to millions of Americans each day. The Alliance for Home Health Quality and Innovation’s research initiatives are a positive step in that direction – we must continue to build a body of research that is valid and constructive.

Second, Dr. Landers could not be more right -- the lack of integration between EMRs and home health records poses a significant challenge. Our hospital partners are looking to us to help them transition their patients safely home after receiving acute care, but without a clean way to exchange information in real-time, improvements will lag behind. There must be a clear roadmap for how to do it and an incentive to make it work.

Last, but not least, as a physician who has practiced medicine for more than 30 years, I believe strongly that well-trained and qualified advanced practice nurses and physicians assistants are needed now, more than ever to join us in the care for the chronically ill at home. There is a shortage of primary care physicians that care for these elderly patients with chronic diseases. Working alongside these physicians, advanced practice nurses and physician assistants can help improve the communication, quality of care and outcomes of our shared patients if they were allowed to play a more meaningful role.

The time to prove the value of home healthcare is now. The time to make sure we’re a connected healthcare system that can exchange real-time information throughout the continuum is now. The time for collaboration across the spectrum of clinicians to make a difference in caring for our chronically ill population is now.

Well said, Dr. Landers. Thank you for your leadership on these issues. We hope your perspectives also hit home with the key regulators and policy makers we need on board to press forward.

About the Author

Michael Fleming, MD, FAAFP is the Chief Medical Officer for Amedisys, and Past President of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians. Dr. Fleming has served as Speaker of the Congress of Delegates of the AAFP and as Board Chair of the AAFP Board of Directors. He serves as an assistant clinical professor in the Department of Family Medicine at the LSU Health Science Center and in the Department of Family and Community Medicine at Tulane University Medical School.
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New Mt. Sinai Research on Hospice Care Benefits

Posted 3/15/2013 Categories: hospice, research, chronic care

The March 2013 issue of Health Affairs features new empirical research on hospice care from Mt. Sinai. The article, "Hospice Enrollment Saves Money For Medicare And Improves Care Quality Across A Number Of Different Lengths-Of-Stay," validates the integration of hospice care for delivering three main benefits:

  • Improved quality of care
  • Medicare cost savings
  • Reduced use of hospital-based services

Click here to read the full article
Amy S. Kelley, Partha Deb, Qingling Du, Melissa D. Aldridge Carlson and R. Sean Morrison. Hospice Enrollment Saves Money For Medicare And Improves Care Quality Across A Number Of Different Lengths-Of-Stay. Health Affairs, 32, no.3 (2013):552-561

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Longitudinal Chronic Care Needed to Reduce Burden of Disease

Posted 12/20/2012 Categories: heart health, home health, diabetes, chronic care

Last week an important new study drove home a point that deserves wider attention. It is this: managing chronic disease requires an effort that is sustained 24 hours a day, seven days a week, 365 days a year. And no approach is better equipped to achieve that objective than the new, ever-evolving discipline of healthcare at home.

The study, published in the British journal, The Lancet, took a look at the global burden of disease over the last 10 years. It came as no surprise to me that the single biggest contributor to this burden is chronic disease. As life expectancy climbs in the U.S., so, too, does the number of years people will live with chronic diseases ranging from diabetes and high blood pressure to heart disease and mental health disorders. This shift in longevity calls for the U.S. healthcare delivery system to change its paradigm, and dramatically so.

That overarching shift in strategy can only be accomplished through a model that truly integrates and coordinates care – and that, more specifically, partners primary care physicians, nurse practitioners, therapists and other healthcare professionals with providers of high-quality healthcare at home. Healthcare delivery should no longer consist, for example, of a twice-a-year check for a blood pressure or a four-day hospital visit for pneumonia. That kind of episodic engagement, though highly valuable, ultimately represents short-term thinking.

Rather, healthcare has to be practiced year-round, and even minute-by-minute. Managing patients with chronic disease should involve daily monitoring of the most vital criteria, including blood pressure, diet and physical activity. Only then can our patients meet the daily functional goals of day-to-day living.

Others have made this argument before. Dr. Ed Wagner and colleagues at the MacColl Center pioneered a model of chronic care management that incorporates these principles. Susan Dentzer, editor-in-chief of the policy journal Health Affairs, said this model “delivers superior patient care and health outcomes.” In short, primary care teams everywhere must reorient themselves. They must team up ever-more with the highly skilled clinicians who are increasingly deployed to care for patients at home.

You can read the entire Global Burden of Disease study at The Lancet.

About the Author

Michael Fleming, MD, FAAFP is the Chief Medical Officer for Amedisys, and Past President of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians. Dr. Fleming has served as Speaker of the Congress of Delegates of the AAFP and as Board Chair of the AAFP Board of Directors. He serves as an assistant clinical professor in the Department of Family Medicine at the LSU Health Science Center and in the Department of Family and Community Medicine at Tulane University Medical School.
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Discuss Patient Goals of Care for Home Health and Hospice Month

Posted 11/19/2012 Categories: chronic care, home health, patient goals of care, hospice, caregiving

As patients age and develop chronic medical conditions, they usually begin to modify their medical care goals. The burden of chronic illness and its associated debility causes many people to want to alter their medical treatment to meet their goals.

Unfortunately many health care professionals neglect to ask patients about their goals of care. In the haste to provide state-of-the-art complex medical care, whether in the hospital, clinic or home environment, many practitioners simply don’t think about asking patients what is important to them. Sometimes it’s assumed that the patient’s goal of care is obvious or the same as our goal. This assumption can lead to scenarios in which elderly patients receive care that is overly burdensome and undesired.

Most physicians and nurses don’t need to think long to recall patients we know who received medical care they didn’t want. In my primary care and hospice practice I encountered numerous elderly patients who had been treated in the intensive care unit with intravenous infusions, ventilators, dialysis and invasive monitoring devices, and after discussion with the patient and family it became clear that this treatment was never desired by the patient. The problem, of course, was that the physicians and clinicians involved didn’t take the time to ask the patient about his or her wishes.

As we celebrate National Home Health and Hospice Month and Amedisys’ 30th birthday, we urge the health care community to give patients and their families the best gift we can: a discussion with them about their goals of care. Whether you are a physician, nurse, social worker or other caregiver, take the time to sit down with your patients and ask them about what they want in their care plan.

You might ask questions like these:

  • In terms of your medical treatment, what is most important to you at this point? For example, are you interested in getting stronger, reducing the medications you take or strengthening relationships with your family? Is symptom control most important to you or is living as long as possible most important to you?
  • In what setting do you want to be treated? Do you want to go to the hospital or would you rather be treated at home if possible? If needed do you want to go to an assisted living facility or nursing home?
  • What treatment burden are you willing to accept? Would you agree to dialysis if your doctor ordered it? Are you willing to have surgery or be placed on a ventilator?

We must acknowledge several realities when asking patients these questions. First, some patients have goals that are unrealistic. Patients may want to stay at home even when they are unsafe at home or have family members who are unable to care for them. Patients may want their medical problems treated without making necessary lifestyle changes. Second, as patients’ conditions change their goals may change. Finally, patients may not be able to easily answer these questions.

Even though these issues are real, it doesn’t mean we shouldn’t ask the questions. Oftentimes the most difficult discussions are the most important ones to have in health care (learn a helpful technique for difficult medical conversations here). Excellent clinicians will repeatedly discuss these issues with patients so they can continue to clarify and reach realistic goals over time. Only then can patients receive the type of medical care they want in the location of their choice and in a way that will help them reach their goals of care.

Five Wishes Advanced Care PlanningFor detailed advanced planning that patients and their families can work on together, you might suggest Five Wishes. The Five Wishes workbook is a clear, simple way to talk about plans for care at the end of life, and is legally valid in 42 states. Download a copy of Five Wishes »

About the Author

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

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Choosing the Right Primary Care Physician for the Right Stage of Life

Posted 7/19/2012 Categories: chronic care, independence at home, primary care, caregiving

One of the most important relationship decisions you’ll ever make is selecting your primary care physician (PCP). Ideally, you’ll be involved with your PCP for a long time, so it’s important to find one who you trust.

PCPs are your home base for health care. You’ll see them for most of your non-emergency needs including preventive care, routine check-ups, and most illnesses. If you need a specialist for a condition or illness, PCPs will refer you to someone appropriate.

As important as they are, choosing a PCP takes a little bit of research. The first step is asking around. Ask your friends, neighbors and relatives who they see and if they are happy with their provider. You can also check with your insurance provider for directories that can help you make the right choice.

Once you’ve narrowed it down, schedule a preliminary meeting with your top choices to get a feel for care style. The Mayo Clinic recommends you choose a provider who:

  • Makes you feel comfortable discussing health topics
  • Answers your questions
  • Communicates well, speaking in terms you can understand
  • Doesn’t make you feel rushed
  • Suggests ways to improve your health
  • Recommends screenings and exams appropriate for your age and sex
  • Treats common illnesses and injuries
  • Involves you as a partner in your care—asks what you think, listens to your concerns and expects you to follow through with action when required
  • Explains the options when you need treatment
  • Offers referrals to highly qualified specialists when necessary
  • Has a convenient location from your work or home
  • Offers convenient hours and appointments without long waits

The information on this page is provided for informational purposes only; Amedisys does not endorse any particular provider. Please carefully evaluate whether any provider or supplier is able to meet your needs.

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