1. Denholm, Erin M. MSN, RN, RWENF

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Blockbuster had Netflix; the taxi industry has Zip Car and Uber; the home care industry has population health. What are the commonalities? They are all disruptors that invoke radical change creating opportunities for entrepreneurs and challenges for legacy systems. For decades, the home care industry has largely been defined by eligibility criteria from payers, private and public, with multitudes of regulation and bureaucracy. Although competencies have been developed over time regarding appropriate care models for sustainable programs, the real ability to create models that engage consumers in not only managing but improving their optimal level of health has been left largely undeveloped. Changing the business model (how we are paid) enables remarkable innovation opportunities.


So what are these innovations? Are there any out there from which we can learn? In the late 1990s, many of us who are part of integrated delivery systems dove into the unchartered waters of capitation. Without big data or competencies in risk stratification or population segmentation, we simply looked to establishing specific goals with the patients and "managing" utilization in hopes of doing our part in controlling costs. Most experiments in the 1990s took significant losses. The resurgence of like thinking packaged differently (population health) enables providers to not only look back to recall lessons learned but evolve the conservative innovations in our legacy systems. Let's look at a case study.


Community case management was very popular in the capitated systems of old. Extensions of home care, the aim of such a model was to evaluate the patient's home environment and identify social, physical, psychological, and emotional determinants that might factor into an individual's downward spiraling that would land them in the emergency department (ED) or inpatient units. Social workers and nurses alike were hired as these community case managers and although they had some effectiveness, there was a lack of integration and data warehousing that would allow targeted proactive interventions. Today, care coordination is the distinctive competency (or secret sauce) that everyone is talking about. With rapid adoption by payers, physician organizations, and employers, care coordination is a must in any population health plan. The truth is care coordination is home care. Based on a foundation of engaged consumers and improved technology, people are identified based on prior healthcare utilization (number of ED and inpatient stays), disease categories, and social, psychological, and emotional elements that are predictive for future high-cost care. Services are then provided preventatively, without considering any eligibility criteria.


An example of a successful program that provides postacute care coordination involves a review of all patients who are part of an accountable care organization, which have come to an ED and have been discharged home without any follow-up services. Patients are called and given a brief risk stratification survey. From this information, people are either:


1. Reminded to follow up with their primary care physician (PCP) in the next 24 to 36 hours.


2. Evaluated for home care services and if appropriate their PCP is called to advise of eligibility.


3. Set up for home safety evaluation.


4. Referred to ambulatory care coordination.


5. Referred for telemonitoring.



Using the subject matter expertise that has developed over decades, home care professionals are indeed the care coordinators that can use the amazing data. We are able to deduce from analytics on attributed populations to provide the very best care at the right time in the right place, home, which is the lowest cost site AND produces the best outcomes. We have learned that if we are unable to identify key performance indicators (success factors) and measure them, there is little chance of being part of the total solution.


Additionally, the emerging success of telemonitoring, which is the ability to provide home care virtually, allows us to further establish our value proposition in population health. Multiple stories have been realized through telemonitoring. Atrial fibrillation identification that enables referrals to PCPs and treatment without an ED visit, bradycardia identification that leads to a cardiology referral and pacemaker placement without an ED or intensive care unit visit, identification of nutritional mismanagement in real time with objective weight devices that prevent heart failure exacerbations or hyperglycemia effects on patients with diabetes. The examples are countless. The impact of such devices on anxiety has been an unexpected consequence. Most notably, with chronic obstructive pulmonary disease patients, who can experience a pathophysiological hypoxic state due to anxiety, telemonitoring can provide the reassurance that "they are OK" and mitigate a crisis trip to the ED. There is a safety net being provided that provides the sense of well-being that not only renders high satisfaction but decreases cost of care as well. As home care professionals, we should own this innovation as it continues to evolve.


With a history soundly in public health nursing, we should be buoyed by these times. Being at the forefront of evolving home health to home-based care, applying learning from the past and innovating for the future, it is time for us to courageously lead in the field of population health. We know how to support people in their home settings like no other. We need to shake off the bondage of payer-defined services and regulations, lest we be categorized with Kodak or Blockbuster.