Patient Navigator Program - How to increase referrals and decrease readmissions.

Boardwalk Homecare, the leader in home care services for New Jersey, is excited to announce the launch of its Patient Navigator Program.

In the wake of the Hospital Readmissions Reduction Program (HRPP), our unique program has been designed to drive collaboration among home care providers, skilled nursing facilities and hospital systems with a key focus on improving patient outcomes.

About the Program
The Patient Navigator Program acts as a bridge to help families connect with the right level of care as they transition from hospitals to rehabs and then eventually back to their home. The program uses a combination of tasked personnel as well as intuitive software and procedures to improve patient monitoring within the first 30 days of being discharged from a hospital and beyond.

Patient education is a key driver of the program. Boardwalk Homecare's case management team spends a considerable amount of time helping families understand and navigate various home care options prior to discharge. Additionally, families are assisted in developing an action plan prior to returning home to help with the transition, service expectations and patient supervision.

Once Boardwalk Homecare patients are set up with services, they are quickly introduced to our team of professionals who will take on an active role in orientating and monitoring the patient’s health, needs and progress. The Patient Navigator Program has triggers in place to identify possible complications and remedy them in an efficient manner with the support of our case management team.

Boardwalk Homecare’s program also aims at keeping open lines of communication in relation to patients, caregivers, family members, healthcare practitioners and skilled nursing facilities. It is our belief that a patient’s home care success is highly determined by a motivated team of individuals who share a common goal and are willing to work closely together for the welfare of the patient.

The Benefits

• Social Work: Case Managers at Boardwalk Homecare are committed to helping improve the discharge readiness of patients requiring higher levels of care. Our team of case managers are available to meet with patients and their families in advance to fully comprehend circumstances, care requirements, concerns and priorities. As experts, our Case Managers will present all available home care options, preparations and best practices needed to maintain a safe discharge home. 

• Administration: Boardwalk Homecare’s team of Registered Nurses and Case Managers will use internal systems to create and closely monitor patient progress and records throughout the first 30 days from a hospital discharge. Our Certified Home Health Aides are also trained to detect and report any change or decline in a patient’s health using the Stop and Watch – Early Warning Tool. All 30 day reports will be sent to the appropriate facility for their own records. If a patient’s health noticeably declines, Boardwalk Homecare will also look to coordinate with healthcare practitioners to determine the best option for avoiding a trip back to the hospital – one choice may include coordinating a readmission to the SNF. 

• Admissions: Boardwalk Homecare will continue to document all patient hospitalizations beyond the current 30 day period set by the CMS. In addition, our case management team has been authorized to notify the appropriate SNF about any of their former patient’s recent hospitalization. This new level of proactive communication will assist SNFs in potentially pre-booking former rehab patients back into their facility to drive a higher level of continuity and quality of care. 

Ready for Results?
Boardwalk Homecare’s Patient Navigator Program promotes patient-centered collaborative care and we believe it will prove useful to SNFs looking to improve the outcomes of discharged patients, advance their level of trust with partnering hospitals and to generate home care referrals.

Over the past 3 years of internally tracking 30 day discharge dates (from SNFs...which goes well beyond hospital discharge dates) and the hospitalizations of Boardwalk Homecare patients, the implementation of our unique program has resulted in ZERO hospital readmissions as per the criteria outlined by CMS. Due to the incredible success internally, Boardwalk Homecare has engineered the Patient Navigator Program so that external SNFs can also experience its success.

If your team is seeking better results with a home care company and would like to pilot the Patient Navigator Program, please feel free to contact Boardwalk Homecare.

To download a copy of the Patient Navigator Program brochure CLICK HERE.

5 Tools to Help Keep Elderly Relatives Safe

Mom and Dad are aging. What makes them different than their parents is that many more of them are planning on staying home. Indeed, more aging Americans are choosing to stay home rather than pack up to move to an assisted living facility. For some of their children, this may be cause for alarm. Will they be ok at home? Will they be safe?

With the increasing trend of the elderly choosing to stay home, there is a burgeoning industry exploring ways to make senior safety more widely available, affordable, and effective. A major concern families of the elderly have is keeping an eye on their loved ones when they can’t be there in person. The following are five tools available right now to help keep an elderly family member safe at home.

Emergency Phone Routing

PERS or Personal Emergency Response Services have been around for awhile. They have been effectively field tested and have repeatedly shown that they can save lives. They consist of a pendant or wrist device that, with a single push of a button, routs a call to a home-base system plugged into a landline. Most of these devices allow for two-way communication. In case of a fall or similar situation where an elderly person can’t get to the phone, this is a lifesaver. PERS companies typically charge a fee per month to provide their service. Popular services include Life Alert, Medical Alert, Alert1, AMAC, Philips Lifeline, and ADT.

Video Monitoring

Video monitoring systems are becoming popular for multiple reasons, including for security, or for monitoring a child or pet. The technology has improved over the years and the cost of a video monitoring system is lower than ever. Cameras can be set around the home and connect to each other through Wifi signals. Video feeds are sent to your smartphone, tablet, computer, or a monitoring service so that you can keep tabs on an elderly relative. Although camera capabilities will vary, the best devices all provide wide-view angles, HD quality video, night vision, built-in motion detection, and sound detection that can notify you when something is happening. Be wary, however, as privacy is a concern among the elderly who require care. Some may welcome the idea, but others will outright reject it. Nest Cam, Piper NV, and Simplicam provide quality products and services to make safe your loved ones.

Sensor Systems

If you or your parents are uncomfortable with video monitoring, sensors may be a good alternative. Sensors can be planted almost anywhere in a home and are much less invasive. They can be attached to doors, a refrigerator, chairs, beds, etc. They send signals right to your smartphone letting you know when a sensor has been triggered and at what time. They can also tell you the last time the sensor was triggered. This allows adult children to know if their parent has left the house, gone into the bathroom, opened their refrigerator, opened their medicine cabinet, or if they are sitting in their living room chair. Abnormalities will indicate that the parent may need to be checked on. Grandcare Systems, BeClose, Lively, and Evermind are all great services with sensor technology.

Mobile Apps

An increasing number of mobile apps designed to help care for seniors are beginning to flood the market. These smartphone apps can work in conjunction with sensor or camera systems. Mobile apps partner convenience and practicality. Apps can also be used by caregivers as a resource complete with helpful tools and two-way communication such as AARP’s Caregiving app. Whether it is setting calendar dates for doctor’s appointments, setting reminders for taking medications, or keeping track of allergies and other special needs, mobile technology is

improving the lives of both patients and caregivers alike. The home care industry has made several attempts to create apps that connect patients and their families with caregivers. There is yet to be any one app that stands above the others, but there are several companies hard at work to find the right balance of convenience, trust, and reliability that patients expect from a home care app.

Internet-Connected Assistants

Although not originally intended for elderly care, internet-connected assistants show a tremendous amount of promise for helping seniors and those who care for them. Internet-connected assistants are devices that incorporate a wide range of tools to help users manage all of their household appliances in one place, such as locks, clocks, cookers, alarms, thermostats, and almost any electrical device around the house. If it can be plugged into some kind of socket, the chances are that internet-connected assistants make its associated tasks easier in some way. One of the best rated devices on the market to date is the Amazon Echo, a device now made famous by its celebrity endorser, Alec Baldwin.

Improve Communication With Clients

As part of research for the 2016 Home Care Benchmarking Study, Home Care Pulse’s data analysts discovered that clients’ likelihood to recommend a provider is more closely related to their satisfaction with office staff than their satisfaction with their caregiver. So while many providers focus the majority of their resources and energy on improving their caregivers, they may want to shift their focus to improving office staff communication with clients. Here are a few tips to get started:

Be Consistent
People are creatures of habits. They like consistency and reliability, especially when it comes to their care. You clients want to trust your company, but in order to do this, they need the stability that comes through consistent communication. Set clear times or situation in which you plan to call them, and let them know when those times will be. They may be weekly check-in calls or monthly home visits, or they may be a monthly letter about billing or a daily text message. Regardless of your medium, make sure you’re consistent and that the client knows from the beginning when and how often to expect communication.

Be Prompt
As soon as you are aware of a problem (an error in billing, a schedule change, etc.), inform your client. Let the client know what has happened and how you plan to resolve it, as soon as possible. Forgetting to inform the client, or informing the client only moments before a big change makes your company look sloppy and irresponsible. Make it a priority to contact your clients with promptness, and provide them with updates or additional information as necessary.

Be Flexible
Whenever possible, let your clients determine how often and by what means they’ll receive communication. When you begin services with a client provide them with a few options for communication and then respect what they choose. Perhaps they would like a weekly check-in, or perhaps they’d rather have bi-weekly or monthly calls. If they prefer email or snail mail, accommodate those requests as best you can. When you communicate with your clients using their preferred method, they’ll be happier and more likely to respond.

Be Personal
Conversations with your clients should be more than just factual. They should be personal. When you check in with your clients, be sure to ask how they are and to listen to the answer. You shouldn’t merely rush through the weekly schedule and then end the conversation. Take a few minutes to ask them about their day and their upcoming activities. Write down any key events that are happening so you can follow up the next week. As you engage with them in personal conversation, you’ll build a lasting and trusting relationships based on solid communication.

Boardwalk Homecare Client Survey - Question #4

The strongest relationships are built upon mutual trust and quality communication. Start working with your staff to improve these fundamental areas of communication. As you do, not only will clients be more satisfied with your services, but they’ll also be more willing to tell their friends.

Boardwalk Homecare expands Hourly Services using its Case Management Approach

Neptune, NJ, March 22, 2016 - Since 2006, Boardwalk Homecare has been providing quality live-in home care throughout New Jersey. Mindful that long-term care planning has become sophisticated for discharge planners and onerous for their patients, Boardwalk Homecare embarked on a unique strategy that did not exist in a very crowded home care industry.

Over the course of 10 years, Boardwalk Homecare has developed a Case Management Approach to home care focused on the following principles:

• Be Compassionate, for Everyone You Meet is Fighting a Harder Battle – Help families overcome the stress involved with arranging for elder care on behalf of a loved one.

• If You Want to Do Great Things, Take the Time to Educate - Help families make elder care decisions based on presenting ALL options, merit, suitability and sustainability and NOT by steering them towards a specific provider agenda.

• Better Manage Continuity of Care Through Case Coordination – Help families obtain peace of mind by assigning dedicated case managers to ensure the safety and well-being of their loved ones.

Licensed in New Jersey as a Health Care Service Firm, Boardwalk Homecare’s operation provides much more than the state requires. Boardwalk Homecare’s case managers are proficient at improving communication, education and support for patients planning to return home.

“No other home care provider has made this kind of commitment in supporting not only the initial urgency but more importantly the ongoing responsibility a family faces with managing home care services,” said Brendan Watson, Co-Owner of Boardwalk Homecare. “Discharge planning can be very time-consuming and a patient’s success is typically left to their own devices once they are back home. Boardwalk Homecare’s Case Management Approach addresses both of these needs.”

Boardwalk Homecare looks to build upon their success with live-in care and expand hourly services throughout Monmouth County. Dedicated case managers will continue to play a critical role in providing ongoing education and support to any family exploring home care services.

To simplify the process even further for discharge planners, patients and their families, Boardwalk Homecare does not require ‘minimums’ and has adopted a single flat rate for hourly services.

For more information or to request literature, please contact Boardwalk Homecare.

Company Contact
Brendan Watson, Owner
732-361-7901
watson@boardwalkhomecare.com

GROUNDBREAKING STUDY HIGHLIGHTS LINK BETWEEN HOME CARE AND DECREASE IN HOSPITAL READMISSIONS

Study Shows 30-percent Lower Need for Hospitalization, Millions of Dollars Saved 

Patients who utilize Medicare home health care after a hospital stay are at least 30 percent less likely to require another hospitalization within 30 days, according to a new study released today by the Home Care and Hospice Association of New Jersey.

 

The study comes on the heels of the state’s recent recognition last summer of having the highest percentage of hospitals — 97 percent of the state’s 64 facilities — penalized by the Centers for Medicare & Medicaid Services (CMS) for failing to curb high readmittance rates of Medicare Fee-for-Service patients within 30 days of their initial discharge.

“Those of us in the home care industry have known for a long time that home health care leads to lower rates of readmittance and greater savings to our health care system,” said Chrissy Buteas, President and CEO of the Home Care and Hospice Association of New Jersey. “And now a careful look at the data proves this point. When patients take advantage of home health care, they can dramatically reduce their chances of landing back in the hospital.”

The study was conducted by the Quality Insights Quality Innovation Network, contracted by CMS to improve quality of health care for Medicare beneficiaries in New Jersey, Delaware, Pennsylvania, West Virginia, and Louisiana, and focused on Medicare Fee-for-Service claims from 2014.

The 30-day hospital readmission rate among beneficiaries receiving home health care services was 17.2 percent, as opposed to 24.5 percent among those who received a home health care referral but refused the service. For patients living with multiple (four or more) chronic illnesses, the disparity was even greater, with 23.7 percent of home health care recipients requiring a readmission as opposed to 31.8 percent of those who refused home health care.

Overall, the study suggests that approximately $6.9 million could have been saved from the Medicare system if patients who refused home health care services following a hospital discharge had instead taken advantage of them.

“Home care works because registered nurses and therapists are trained to recognize the subtle differences in a patient’s condition to make a medically sound assessment of which symptoms require a trip to the hospital and which do not,” said Buteas. “More importantly, as this study suggests, home care is playing an important role in allowing people to manage their health not in a hospital, but in the place in which they are most comfortable, their own home.”

Why Choose Live-In Care?

There are many instances where home health care is required but why choose a live-in caregiver vs. hourly care for your loved one? Live-in caregiver offers the optimum in home health care at a more affordable rate. Did you know that the daily flat rate for a live-in equates to about nine hours of hourly care? Not only is this a significant financial value, but your loved one benefits from a caregiver being in the home around the clock.

Continual Trust
In addition to affordability, a live-in caregiver can offer unsurpassed care and companionship. Your loved one can develop a trusting relationship with his or her caregiver. Likewise, your caregiver will really get to know you or your loved one, including his or her daily activities and preferences. Everything from a favorite lunch to preferred hobbies and pastimes. Live-in home care offers your caregiver and your loved one a chance to become friends.

Continual Care
There is nothing more important than continuity of care for your loved one day in and day out.  A live-in caregiver is always there, providing the same caring style seven days a week, with no disruption to the client’s routine. A live-in caregiver is dedicated to ensuring constant and consistent home health care. Even when your caregiver needs a day off, most agencies provide a trained relief caregiver to ensure continuous and seamless care.

Continual Comfort
Opting for a live-in caregiver to care for your loved one can also be a constant source of comfort. Nothing compares to knowing that a quality, trained and compassionate caregiver is with your loved one at all times. Finding consistent, quality of care from a licensed home health agency you can trust is essential to your peace of mind.

When to Consider?
What are some life circumstance examples where live-in home care assistance is especially useful? 24-hour home care assistance is especially useful for anyone with Alzheimer's disease or memory conditions that may cause them to wander, to forget medications or maintain nutrition. It is also beneficial for a person who is a fall risk at night when getting up to use the restroom or is generally frail when moving about. If someone is not able to respond to an emergency and would need assistance, then the presence of a live-in caregiver is needed for both safety as well as comfort. Live-in home care assistance is obviously needed for any bed-bound person who needs total assistance. It is also useful for people who feel anxious or get lonely easily or who have incontinence and cannot do all of their personal care on their own. 

Top 5 Policies for Live-In Home Care Services

While there are a number of policies and procedures to consider in creating a successful live-in home care experience, the following are some key ones that should be addressed right at the start! The list has been comprised using the 80/20 rule (roughly 80% of the effects come from 20% of the causes).  Here are the Top 5:

1. Job Description: While licensed home care providers will institute a Plan of Care for their caregiver to follow based on a nurse assessment, families who hire a caregiver privately are encouraged to clearly identify every task the caregiver will be responsible for performing. In addition to describing which personal care (ADLs) and homemaker (IADLs) activities are required, it is equally important to determine the daily routine. Details around the care recipient’s routine should cover time of day and/or frequency of when specified activities should be performed. Additionally, the routine should include instructions on how to perform these activities to the liking of the care recipient or their family.    

2. Defining the Workday: Based on Department of Labor regulations, licensed home care providers will define the number of hours a caregiver is expected to work in a 24 hr. period. This is typically between 8-13 hrs. per day (a standard set of hours has not been adopted across the industry yet because new federal regulation was recently passed and licensed home care providers around the country are still trying to figure out its application to live-in home care). The two most important aspects both licensed home care providers and families hiring private caregivers will be to establish the critical times of day for the care recipient and the uninterrupted sleep time/meal times/ break periods for the caregiver. In defining the workday, it is very important to allocate appropriate times in the day (e.g. break periods) for when the caregivers can use the time for their own purposes such as making calls on their cell phone, using the internet, watching television, exercising or reading.  

3. Food Appropriations: We have covered food appropriations extensively in the past. This is because it can be a pretty big hurdle if left unaddressed. The three key aspects to food appropriations include: food expense, food purchasing and food preparation. The food expense should cover whether or not the family provides the food for the caregiver or if they would prefer giving the caregiver a daily food stipend. The food purchasing should go over who is responsible for buying groceries and what the process is for doing so. In addition, methods should be put into place to limit identify theft (using debit cards, credit cards or checks) and to track petty grocery cash and receipts. The food preparation piece should go over cooking safety, meal preferences as well as any type of diet, allergy or nutrition requirements of the care recipient.

4. Theft Prevention: The mission should be clear – implement methods to prevent the loss or theft of care recipient valuables. Some of this risk can be reduced prior to hiring a caregiver by conducting criminal background checks and purchasing insurance coverage such as a commercial crime bond. Additionally, families are encouraged to safeguard a care recipient’s valuables and keep them out of reach from people in and out of their home. For care recipients suffering from a neurological impairment, such as Dementia, it may also be a good idea to keep a detailed inventory of personal items in case they become confused or paranoid. From a policy perspective, families should be very clear on their position when it comes to giving gifts to caregivers and under what circumstances – if any – it would be permitted.

5. Emergency Preparedness: Orientating caregivers on emergency planning is certainly a topic that needs to be addressed. It should begin by providing a list of contacts and their phone numbers (family members, neighbors, doctors, fire department, etc.). The list should identify and prioritize who should be called in the case of any specific events. Clearly the primary care physician would not be the first one called if the household has run out of milk! In all seriousness, it is too often that incidents are not reported by caregivers so families need to be firm on the protocol and make sure the caregiver understands the importance of notifying them on a regular and/or emergency basis.