Home Health & Chronic Care Partnerships for Success

Home Health & Chronic Care Partnerships for Success

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Erin Cahill: Welcome to the CareSmartz360 on Air, a home care podcast. I’m Erin Cahill, an Account Executive at Caresmartz. While home health aides provide in-home care, chronic care specialists remotely monitor and manage long-term conditions like diabetes or heart disease. By working together they can bridge the gap.

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Erin Cahill: Home health aides can report the seniors, vitals, and medication adherence to the specialists who can then adjust treatment plans or raise red flags with doctors. This communication loop keeps the elderly healthier and avoids unnecessary hospital visits. Further home health agencies can expand their services by offering chronic care management programs while chronic care providers gain a valuable in-home resource to enhance elderly well-being.

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Erin Cahill: It’s a win-win for both sides and most importantly for the seniors who rely on them.

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Erin Cahill: Today we have Karen Gomes, the owner and founder of Rn. Answers, Llc. On the panel. Karen provides home health and Hospice organizations, and executive-level services, including leadership mentoring and Coaching Board, development, Strategic Planning and program development welcome to the Podcast Karen.

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Karen Gomes: Thanks, Erin. Great to be here.

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Erin Cahill: So we’ll jump right into it. Can you explain the different types of home health and hospice services available?

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Karen Gomes: Sure. Well, you know, I think many of your clients are what we would kind of think about in terms of supportive care. So it’s non-medical but they offer really important services to, you know, elderly people in particular. But anyone who needs a helping hand at home to help them remain at home. That can be really long-term service. Sometimes it’s partially covered by state funds, sometimes it’s private duty.

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Karen Gomes: But you know they do everything from helping with meals with mobility, with bathing and dressing all of those kinds of supportive activities of daily living that people sometimes struggle with and without that, supportive in-home care people may end up in a nursing home. Then there are skilled levels of home care as well, and those typically don’t last long term, but they’re they’re ordered by a physician to address a more specific

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Karen Gomes: sometimes short-term issue, but sometimes longer term as well.

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Karen Gomes: So if an elder is in the hospital, say, with an acute exacerbation of a condition, they may be discharged home with skilled home care and a nurse and typically a physical therapist or occupational therapist will evaluate them in their home, make recommendations for new equipment, review all of their medications do a lot of teaching, and just kind of assess to make sure that.

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Karen Gomes: But they are stable after their hospitalization. Sometimes patients may have had surgery, and they need wound care and that sort of thing, all of that is covered by skilled home health that is typically paid for by Medicare or by other private insurance, and then the other really big component of in-home care is hospice care most? If not,

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Karen Gomes: I would say it’s probably close to 90% of Hospice care. Delivery is delivered in patients, individual private homes rather than in hospice facilities.

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Karen Gomes: and hospice is a service for people whose expected life expectancy is 6 months or less so in order to qualify for hospice, a doctor has to deem the patient as someone who has. You know that shorter window, remaining in their lives. And basically the goal of Hospice is not to cure or prolong their illness, but instead, to.

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Karen Gomes: you know, help them achieve the best quality of life that they can for the time that they have remaining and they will often both skilled home health and hospice will often partner with supportive care. Agencies. To really kind of provide that wraparound level of care that’s needed to keep people, you know, safe and at home.

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Erin Cahill: Right, and how do you assess an elderly needs to ensure they receive the most appropriate level of care, whether it’s home, health, or hospice.

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Karen Gomes: Yeah. Well, quite often a physician needs to be involved. Because both of those levels of care do require a physician order in order to to be able to, you know, really, or to prescribe the home care or the hospice.

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Karen Gomes: However, family members or supportive care aids can be really alert for changes in condition. And I think that that’s super important. And that’s 1 thing. I think that our home care aids out in the community do a great job. They know their clients really well, and they recognize if somebody’s acting a little bit differently than normal, or they just don’t have the get up and go that they would normally have. Or maybe they’re getting really confused.

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Karen Gomes: And for them to be able to report those observations. Typically, if they’re working in an agency, it would go like a nurse supervisor.

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Karen Gomes: who would then

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Karen Gomes: probably make arrangements to go visit the patient in the home, and or call the patient’s Pcp. And arrange for the patient to be seen in the doctor’s office that can really help

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Karen Gomes: avoid that Ed. Visit in the middle of the night, or that hospitalization entirely. You don’t have to have been hospitalized in order to get skilled home care. So if, then, if an aid in a supportive care situation notices a change or a problem, and reports it promptly. Oftentimes a home health visit can be ordered. You know, through skilled home care, and just avoid that hospitalization altogether.

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Erin Cahill: Right, and how can families navigate the cost of home health and hospice care.

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Karen Gomes: Yeah, that’s it’s really very challenging. I think you have to look at it. Holistically. You know, if you’re not at home, you’re going to be paying, you know, a lot of money for assisted living or nursing home care? So if there are funds in the home and the home is.

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Karen Gomes: you know, physically supportive for the patient, for the client. And they really want to stay there. Sometimes it’s worth spending the money on Aids to help rather than making someone move out of their cherished home and have to pay a lot of money in a facility.

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Karen Gomes: there are programs depending on the state that you live in and depending on the income level of the individual. So if the individual doesn’t have a lot of assets.

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Karen Gomes: Sometimes they qualify, particularly if their condition is such that they would qualify for a nursing home, staying under Medicaid. Many States have programs where they would rather have the patient stay at home, and they’ll use some of the money that would go to the nursing home to pay for in home care in terms of skilled home care and hospice care that is typically

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Karen Gomes: pretty much a hundred per cent covered by the elders. Insurance. However, they’re not long-term solutions, so you know, it can be challenging. It may seem, you know, with an elder who’s been hospitalized, whose discharge plan is home, and they get ordered all of these great services that you know are there in the beginning, but after, say, a month or 2 months they have to

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Karen Gomes: to discharge, and if there isn’t a long-term plan. And you know, family members or friends available to help and if that elder still needs support, they’re really going to need the care of a supportive care agency, and that can be challenging from a financial perspective.

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Erin Cahill: Absolutely.

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Erin Cahill: In what ways can providers of home health and hospice partner for success?

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Karen Gomes: Well, some of the best agencies that I’ve ever been involved with have had both home health and hospice components, and I think it’s becoming even more common. The fact is, seniors in our communities are often within a continuum of care and their care needs change over time. And it’s great if you have the ability

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Karen Gomes: to offer a variety of services, to meet the patient’s needs at the right time, at the right level of care. You know, for their needs in the moment, and that as their needs change, they can progress.

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Karen Gomes: You know, either up or down that continuum and have that real continuity of care of, you know, sometimes even the same aids able to cross over, or nurses that can offer palliative solutions while they’re receiving skilled care. And then, you know, assuming you know the patient.

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Karen Gomes: you know, continues to progress, they may eventually get to a place where they can really benefit. They and their family can really benefit from Hospice. So you know, I think the best way to partner is to really understand your patience.

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Karen Gomes: What their risk factors are, what their goals are. And to really support them, and make sure that they are educated about all of the things that they are potentially eligible for, and that your own agency can provide them. And that’s a great way to maintain a longer-term relationship with patients.

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Erin Cahill: Yeah. Can you share some success stories with providers of home help and Hospice app partners?

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Karen Gomes: Oh, sure, I mean, I’ve I’ve I’ve overseen some of those myself in my career. You know, I think very typically an agency providing skilled nursing care is gonna have a mix of patients. Some patients are going to be, you know.

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Karen Gomes: essentially healthy, and maybe they had a hip replacement, and they need some short-term therapy, and you know some wound care, and then they’re fine, and they don’t need anything further. But a big portion of the home cares. The patient base is going to be patients with 3-plus

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Karen Gomes: chronic conditions. That, you know, really altogether makes it extremely difficult for the patient to manage day to day. They’re often impacted with pain and depression. In addition to really complex treatment plans, they have a hard time. Doing all the time by themselves. They tend to be in and out of the hospital. You know, sometimes 2, 3 times a year.

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Karen Gomes: and as these conditions progress over time. What happens is the Home Health Agency may be involved for a time. Get them stabilized.

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Karen Gomes: discharge. They get called back a few months later and discharged. But over time you really come to recognize that the patient, you know, is having this progressive decline. It’s a trajectory of illness that you can really see, and you can help them kind of grapple with and understand, and as their needs change

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Karen Gomes: if the Home Health agency has, say, a palliative care nurse, practitioner. She can go in there into the home and really work with the patient. What? What are the things that are

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Karen Gomes: particularly

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Karen Gomes: difficult for them to deal with from a symptom burden perspective depending on their illness, and they can really work with them to focus more on symptoms and less on, you know, curing is, there really is no cure for these chronic conditions. And over time, as things go, you know, it’s just a. It’s a beautiful synergy of

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Karen Gomes: home care, professionals working closely with patients and families and bringing that care all together so that they really feel like, you know. It’s so much more than a warm handoff. You know where you’re calling some other agency down the road and saying, gee! Now it’s your turn to take care of this patient when it’s done properly.

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Karen Gomes: In a true continuum model within, you know, under one roof. Essentially that patient feels no transition at all. And it’s just kind of a seamless, you know, delivery of care through the entire continuum, and that, I think, is

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Karen Gomes: what serves our elders the best. So that’s what I like to see.

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Erin Cahill: Yeah, absolutely well, thank you so much, Karen, for sharing these great insights. I’m sure the audience got in-depth knowledge about how providers of home health and hospice can partner for success. And to you, my wonderful audience. Thank you for tuning in until the next episode. This is Aaron Cal. Signing off.