Imagine having a nurse visit your elderly mother at home, fully evaluate her health, check for trip hazards and other potential causes of falls, and spend as long as two hours answering her questions, making sure she understands her condition and her treatment.
That is how the VNA of Care New England starts every patient relationship, President and CEO Nancy Roberts says. The point is to prevent future crises – whether it’s a cardiac problem due to a missed medication, or a fall that leads to a hip fracture.
About half the VNA’s patients are referred by hospitals, and the agency works hard to keep them from having to go back. But the nurses, physical therapists and aides only visit for about 60 days; Medicare won’t pay for more.
“It’s really designed to provide a response to a hospitalization or an acute episode of illness,” Roberts said at a forum on home care March 8 sponsored by Quality Partners of Rhode Island and Providence Business News.
Studies have shown that longer-term home care can substantially reduce hospitalizations, Roberts added. “We do know what to do. We just can’t seem to link it with our reimbursement system or with a will to make that commitment.”
Long-term home care is available in Rhode Island, but from an entirely different kind of provider, and mostly involving certified nursing assistants. Low-income seniors can get Medicaid waivers to pay for it, and the state offers a subsidized program as well.
Yet even those resources are limited; Robert Caffrey, president and CEO of Homefront Health Care in Providence, said that while Rhode Island spends nearly $500 million per year on long-term care, “90 percent of that is spent on institutional care,” while other states invest far more in home care.
Mary Linn Hamilton, president and CEO of the VNA of Rhode Island, noted that home care is “the least-cost provider” of services for sick, frail elders. While in 2003, a day in the hospital cost about $4,000, according to the National Association for Home Care & Hospice, and a day in a nursing home, $500, one home health visit by a skilled nurse cost about $110, she said.
And new technology is creating even more cost-effective ways to care for patients at home, Hamilton noted. The VNA of Rhode Island, which has about 600 patients in its care on any given day, now uses telemonitoring to track patients’ vital signs, weight, even wounds, she said, working closely with the patient, caregiver and doctor to respond to any problems.
Home care is also a particularly good setting for preventive care, Hamilton, Roberts and others said. Roberts noted that one-third of people over age 65 suffer an accidental fall each year, leading to 53 percent of injury-related hospitalizations. When the fall leads to a fractured hip, she added, “40 percent of those seniors will never go back to their own home again.”
And because it occurs in the patient’s own environment, with plenty of time, Roberts said, home care can expose problems that a doctor or hospital staff might not see. A patient might say he understands how to take his pills, for example, but if the visiting nurse asks him to show her how he does it, she might get a different response: “I don’t have glasses to see these prescription bottles.”
But there are many barriers to accessing this kind of care, and money is only one of the factors, speakers and audience members at the forum said.
Lt. Gov. Elizabeth H. Roberts noted that for an outsider, it can be hard to connect with the system, much less figure out who’s a high-quality provider. And Maureen G. Glynn, chief of the Rhode Island attorney general’s health care unit, noted that there are now “rogue” providers who aren’t licensed at all, and whose employees have no documented health care credentials.
Janet C. Lowell, executive director of Roger Williams Home Care, said that is “a serious situation,” and “our staff encounter these people in the homes.”
One way that skilled home care providers are trying to connect with patients is by forging closer relationships with doctors, nursing homes and especially with hospital staff. Nancy Roberts said her agency has worked closely with the ER of fellow Care New England member Kent Hospital especially.
Dr. Daniel H. Halpren-Ruder, president of the Quality Partners board and an ER doctor for 25 years, said that absent a relationship with a home care agency, ER doctors are going to be inclined to admit elderly patients, and family members often beg them to do so.
“Those are the people with the patient in the ER, telling the ER doc, ‘I just need a couple of days, doc; can’t you put them in so I can get my life back together?’ ”
