title: Preliminary Data on a Care Coordination Program for Home Care Recipients.
abstract: Home care recipients are often hospitalized for potentially avoidable reasons. A pilot program (Intervention in Home Care to Improve Health Outcomes (In-Home)) was designed to help home care providers identify acute clinical changes in condition and then manage the condition in the home and thereby avoid a costly hospitalization. Caregivers answer simple questions about the care recipient's condition during a telephone-based "clock-out" at the end of each shift. Responses are electronically captured in the agency management software that caregivers use to "clock-in," manage care, and "clock-out" on every shift. These are transmitted to the agency's care manager, who follows up on the change in condition and escalates appropriately. A description of the In-Home model is presented, and pilot data from 22 home care offices are reported. In the pilot, caregivers reported a change in condition after 2% of all shifts, representing an average of 1.9 changes per care recipient in a 6-month period. Changes in behavior and skin condition were the most frequently recorded domains. Interviews with participating caregivers and care managers suggested positive attitudes regarding the intervention; challenges included resistance to change on the part of home care staff and difficulties in applying a uniform intervention to individuals with varying needs in home care offices with varying capacities. In an ongoing randomized trial, the success of the overall program will be measured primarily according to the potential reduction in avoidable hospitalizations of home care recipients and the effect this potential reduction has on spending and healthcare outcomes.
authors: Harvard Medical School, Boston, Massachusetts.
authors: Katie M
authors: KM
authors: Dean
authors: Harvard Medical School, Boston, Massachusetts.
authors: Laura A
authors: LA
authors: Hatfield
authors: Harvard Medical School, Boston, Massachusetts.
authors: Anupam B
authors: AB
authors: Jena
authors: ClearCare Online, San Francisco, California.
authors: David
authors: D
authors: Cristman
authors: Right at Home, Omaha, Nebraska.
authors: Michael
authors: M
authors: Flair
authors: Right at Home, Omaha, Nebraska.
authors: Kylie
authors: K
authors: Kator
authors: ClearCare Online, San Francisco, California.
authors: Geoffrey
authors: G
authors: Nudd
authors: Harvard Medical School, Boston, Massachusetts. grabowski@med.harvard.edu.
authors: David C
authors: DC
authors: Grabowski
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017028:Caregivers / Q000191:economics / Q000193:education; D002908:Chronic Disease / Q000191:economics / Q000628:therapy*; D003194:Computer-Assisted Instruction / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D003266:Continuity of Patient Care / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D017046:Cost Savings; D057286:Electronic Health Records / Q000458:organization & administration; D006284:Health Plan Implementation / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D006305:Health Status Indicators; D006699:Home Care Services / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D033183:Interdisciplinary Communication; D000070516:Intersectoral Collaboration; D008297:Male; D000069342:Medical Overuse / Q000191:economics / Q000517:prevention & control; D010865:Pilot Projects; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D012984:Software
keywords: aging; care coordination; home care; hospitalizations