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(L-R) Dr. Melissa Scollan-Koliopoulos, UMDNJ-University Hospital; Rosa Ortiz, home health aide, Central Jersey VNA

Certified home health aides will play an integral role in efforts to prevent re-hospitalizations when a new project at the University of Medicine & Dentistry of New Jersey (UMDNJ) is launched.

The “I CARE-4-Healthcare Transition Project,” designed to prevent discharged patients from returning to the hospital within the first 30 days after they leave, will utilize a four-tiered approach to care that includes a:

• certified home health aide/patient navigator
• registered nurse
• advanced practice nurse (APN), and
• physician team.

The certified home health aide/patient navigator will be responsible for visiting patients who are in the hospital and following up after they are discharged to the community, a hospital press release explains. The APN will provide care with “physician collaboration until a patient can see a primary care physician regularly.” [Scroll down for a further explanation of home health aides' role in the program from co-director Melissa Scollan-Koliopoulos, Ed.D.]

Reduce Costs, Improve Health Outcomes

A key aspect of the project will be to help patients determine when they need to go to a hospital emergency room or when they should see a primary care physician instead, in order to reduce costs and improve health outcomes.

Educating patients about medications and overall health and wellness, as well as connecting them to resources such as health insurance, are also project goals.

Patients enrolled in the project will receive support in self-management prior to being discharged.

People are eligible to participate in the project if they do not have a regular primary care physician and if they have one or more of the following diseases:

• diabetes
• cardiovascular disease
• respiratory disease
• HIV, and
• sickle cell disease.

“Our goal is to extend the attention and care that patients receive from us beyond the four walls of UMDNJ-The University Hospital, thereby improving patient outcomes,” said David Bleich, MD, a project co-director.

The “I CARE-4-Healthcare Transition Project” will be implemented in partnership with the Visiting Nurse Association Health Group.

The project will be supported by a $300,000 grant from the Robert Wood Johnson Foundation‘s New Jersey Health Initiatives program with additional funding from the Healthcare Foundation of New Jersey.

– by Deane Beebe

PHI Director of Policy Research Dorie Seavey

At the Association of Health Care Journalists‘ annual conference on April 16, PHI Director of Policy Research Dorie Seavey, Ph.D., discussed how direct-care workers’ roles can be leveraged to improve care transitions.

Speaking on a panel entitled, “Hospital to Home: Tomorrow’s Transitional Care Models,” Seavey told more than 50 journalists that, “Without direct-care workers, many consumers simply can’t go home, and back home is usually where most people want to go.”

As people transition from one setting to another, direct-care workers are key to quality care because they:

• provide 8 out of 10 hours of paid long-term care services;
• spend the most time with consumers receiving services; and
• are best positioned to observe changes in conditions and catch problems early.

Yet direct-care workers are a typically a “forgotten resource” in the transitional care team design, Seavey said, even though they are “uniquely embedded” in the lives of their clients.

She suggests that the role of direct-care workers be maximized for innovative cost-control solutions, such as employing them as “foot soldiers” to help monitor chronic health conditions and ensure compliance with medication and health care regimens. Other enhanced direct-care workers’ roles could include:

• continuing care/transition workers who are skilled across settings;
• health monitors for telehealth programs;
• wellness and prevention coaches; and
• outreach workers to family caregivers.

Seavey recommends building direct-care workers into care teams for both transitions and the “steady state,” noting that better care in the steady state would lead to fewer transitions.

To succeed in these new roles, Seavey said, direct-care workers need quality training in:

• observational skills;
• communication and team skills;
• supporting and coordinating with family caregivers;
• behavior management skills; and
• health maintenance and prevention knowledge.

(L-R) University of Pennsylvania School of Nursing Professor Mary Naylor and Dorie Seavey

Leveraging direct-care workers to be a greater asset on the team would maximize the power and effectiveness of the entire team, said Seavey. However, such leverage will require that these workers be respected as professionals and that hierarchies be broken down to allow “all players to work at the top of their licenses, practicing collective care,” she said.

University of Pennsylvania School of Nursing Professor Mary Naylor, Ph.D., R.N., F.A.A.N., discussed her research findings on patients who transition out of the hospital. She reported that one of the core components of transitional care that leads to better outcomes is a nurse-coordinated team model — which includes direct-care workers.

Also on the panel were Emily Saltz, LICSW, executive director of Elder Resources and board member of the National Association of Professional Geriatric Care Managers, and Kathleen Kelly, M.P.A., executive director, Family Caregiver Alliance.

“The direct-care workforce plays not just a huge, but also an important role in formal caregiving,” said Eileen Beal, an editorial consultant on health care and aging issues who organized the conference panel.

“I wanted journalists to understand how important direct-care workers are in the care of not just older people but all people requiring post-hospital and/or long-term care and services, and the challenges they face in the highly fragmented and highly competitive direct-care industry, so that they will cover this workforce,” Beal said.

Seavey’s presentation, Direct-Care Workers and Transitional Care (pdf) is available on PHI’s website.

All of the panelists’ slide presentations will soon be posted on the AHCJ website.

– by Deane Beebe

A recent report issued by the Long-Term Quality Alliance (LTQA) presents three innovative programs designed to reduce hospitalization rates and improve care transitions.

The report (pdf), released in February, is entitled “Innovative Communities: Breaking Down Barriers for the Good of Older Consumers and Their Family Caregivers.”

The report stemmed from a December 2010 LTQA summit meeting, held in Washington, D.C.

Three Case Studies

The “Innovative Communities” report contains three short case studies on innovative programs in North Carolina, Vermont, and Michigan:

• Community Connections in Chapel Hill, North Carolina. This program, spearheaded by the Carol Wood Retirement Community, educates Chapel Hill’s elders about the services and supports available to them locally. The program has sponsored “community engagement events,” workgroups, and a resource center, all designed to teach older North Carolinians about their service and support options.
• Support and Services at Home in Burlington, Vermont. The Support and Services at Home (SASH) program provides an organizational framework for coordinating care in community-based settings. The model revolves around a team of caregivers — nurses, a case manager, a SASH coordinator, and others — to administer care and help develop healthy aging plans for individual elders.
• Detroit Community Action in Farmington Hills, Michigan. A collaboration between five Detroit-area hospitals, the Detroit Community Action program is designed to reduce the need for rehospitalization after patients are released. Through the program, local hospitals schedule follow-up appointments between discharged patients and their primary care physicians, call patients each week for a month after they are discharged, and work closely with providers of post-acute care to help ease patients’ transition to nursing homes.

LTQA Background

Formed in late 2010, the LTQA is an alliance of experts on health and aging issues.

Currently, the LTQA is focusing on developing ways to improve care coordination and care transitions, as well as avoiding unnecessary hospital admissions and re-admissions among elders and people with disabilities.

The next LTQA summit meeting is scheduled for early summer, and will also take place in Washington.

– by Matthew Ozga