At HomeMD Housecall Services, we take post inpatient care seriously. According to CMS, the average hospital stay for a medicare patient is $13,600, which does not include any billing for the consequent rehab stay or the home health nursing care needed to maintain the patient out of the ER. If our transitional care and chronic care management teams can work closely enough with hospitals, home health companies, and other providers involved in a patient’s care in such a way that a single rehospitalization can be prevented, we can save medicare a $13,600 readmission for the lost cost of approximately $250. The fact of the matter is that home health care alone is not enough because the home health registered nurses lack the prescription pads necessary to adjust medications or clinical orders “on the fly”. Unfortunately, a single home health registered nurse with a caseload of approximately 15 clients is likely dealing with the 15 different medical providers who all have waiting rooms full of patients who are demanding of their attention at that place and time. At HomeMD Housecall Services, we do not have waiting rooms, rather, we provide our care inside of livingrooms where we are able to take the time to be on the same page with family members, home health nurses, and all of the other stakeholders caregiving for the patient. Simply put, we increase the ‘bang for the buck’ that medicare is already paying for the patients care after a hospital visit.
What about the time the discharge planner at the hospital level spends making phone calls, then making follow up phone calls, and then making follow phone calls to those phone calls so that something can be coordinated with primary care providers who the patient has not seen in months or sometimes even year? Hospital discharge planners spend a majority of their day trying to control for what happens when a patient leaves the walls of their inpatient facility. All the phone calls, all the faxes, and all of the effort put into guarding a patient from the volatility of things the patient or their families may not know how to control for can go “out the window” when a patient is unable to follow up quickly with a medical provider post discharge. The homecare company that the discharge planner has been coordinating with cannot evaluate or treat the patient in their home (ie. nursing, physical & occupational therapy, home health aid services, etc) without knowing that a medical provider has seen the patient and is willing to cover their orders for treatment . . . at that point, their patients are at very high risk of re-hospitalization. This is where we come in . . .
For discharge planners all over Michigan, we invite you to experience the HomeMD difference! Our transitional care team will work closely with you during and after the inpatient stay so that you can finally trust the system again, knowing that your hard work will not go in vain. We will see our patient (or our new patient per your referral) within 48 hours of discharge and in most cases sooner upon your request should the need arise. This visit may be onsite or telephonic, but either way it will get done and it will get done quickly. We will then coordinate closely with the homecare company of your choosing, or if it is one of our own patients for whom you are coordinating care we will be happy to inform you what homecare company it is that the patient is most familiar with so that continuity of care can be maintained. Allow us to take some of that work off your shoulders so that we may defend your outcomes with you!
Our transitional care team consists entirely of registered nurses who coordinate post hospitalization care so that our patients never slip through the healthcare cracks. Our automated software systems “talk” to your hospital’s software systems, such that we are automatically and seamlessly notified when our patients are admitted to your hospitals, even when they are too sick, too preoccupied with their condition, or too distracted by their illness to let us know themselves. Once our systems are flagged, our transitional care team gets to work, immediately engaging with you and the rest of your discharge planning team so that post hospitalization care can be smooth and well coordinated. Upon discharge, our clinical team reaches out to the patient or their family to setup a post hospitalization visit, generally within 24-48 hours of our patient returning home. At HomeMD Housecall Services we pull off what others can’t . . . whether it be onsite or telephonically driven, we see our patients quickly after discharge so that home healthcare can get on with their treatment plans and so that clinical volatility can be managed.
When the patients you are discharging have needs that are difficult to manage from a clinic based practice, look no further than HomeMD Housecall Services!
Other benefits to consider :
The period of time after a hospitalization is typically the most volatile period of time any patient or their family will experience . . . while we are trained to believe that “I’m all fixed” after a hospitalization, in reality, it is quite the opposite in most circumstances. Hospitals discharge much earlier than they did a decade ago and it is expected by the hospital system that home care nursing companies along w/ primary care teams will work with patients and their families to pickup the baton the hospital is handing them in such a way that they will defend against the risk of the patient falling right back into the inpatient setting. At HomeMD Housecall Services, we don’t just pick up the baton, we run with it!
We understand that after a hospital visit there are multiple people in and out of your home including nurses, physical therapists, social workers, and home health aids. Patients and their families must juggle these appointments, keep other family members updated, arrange for new medications to be picked up and/or delivered , and somehow keep a lookout for declines and new medication side effects that they may not be educated about pertaining to conditions that they are having to lookup on Google. At HomeMD, our registered nurse case managers from our chronic care management team will help you to coordinate all of those things so that our patients and their families can be made to feel that they do in fact have a lantern to guide them through what can otherwise be a confusing labyrinth of a dark cave.
Our staff strives to make each interaction with each patient clear, concise, and inviting and we do the same with the caregiver systems that support our patients, including you, the home care company. We will be there when you call us to give you the orders that you need, that is our commitment to you. No more phone tag, no more voicemails, no more waiting game. Each one of our providers has a dedicated office assistant who can provide you with your frequency orders and changes on behalf of the provider. We will be happy to do telephonic visits while you are with our mutual patients their homes and we commit that you will never, ever have to feel like you are chasing us down. Our field providers are all nurse practitioners so when coordinating care you will be speaking to an advanced practice nurse who has been in your shoes enough to know how very frustrating it can be to wait for clinic based providers to get back to you while making multiple phone calls to get your job done. You know what your patient needs . . . all you want is to be empowered with the tools to make your patient better and we want to be right there with you!
Home-based primary care can enable hospitals, accountable care organizations (ACOs), and Medicare Advantage programs to improve the coordination and quality of patient care on their most costly patients. It significantly reduces expensive nursing home services while boosting patient satisfaction.
The Independence at Home (IAH) Medicare house call demonstration program, which began in 2012, was designed to test the ability of a home-based primary care model to improve care, reduce Medicare costs, and help complex patients age in place. It is completely funded through cost savings generated by the house call practices taking part in the initiative. In its first four years, IAH realized millions of dollars in savings, including $32.9 million – an average reduction of $2,819 per beneficiary – in its fourth year. Beneficiaries had fewer 30-day readmissions, hospitalizations, and emergency department visits. Quality of care also increased in all measured areas, such as follow up within 48 hours of hospitalization, medication reconciliation, and documentation of advanced care preferences.