One in five people diagnosed with chronic illnesses like Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), or who have suffered heart attacks, pneumonia, or injuries from falls cause hospital readmission.
Hospital readmissions are often necessary because people need assistance with both the simple and complex care needs that these illnesses require or cannot accurately communicate her/his condition and symptoms to their caregivers or physicians.
Fortunately, many of these hospital readmission trips can be prevented with an in-home care program that includes proper education and supervision. That’s where HCFA comes in.
HCFA has a time-limited, evidence-based, condition-specific care program focused on empowering the client to better manage her/his chronic illness through the active involvement and oversight of our RN Coordinator and our specially trained care team in collaboration with the client’s primary care team, specialists, and other relevant healthcare team members.
The goals of the program are to enhance the person’s quality of life and reduce negative outcomes, such as potentially preventable hospital readmissions, medication adverse effects, falls, etc. HCFA is inspired by nationally recognized care transition programs, like The Coleman Care Transitions Intervention Program that resulted in a 50% reduction in readmissions after 30 days. Patients in the Coleman clinical trial were more likely to achieve self-identified personal goals for symptom management.
Only HCFA Care can provide this level of comprehensive care thanks to having an RN in every office. The RN Care Coordinator plays an active role in each case by both visiting the client regularly and making sure every CNA or HHA who works on a HCFA case is specially trained in that condition.
Condition-specific diseases with a high risk of hospital readmission:
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure
Pneumonia
Chronic Obstructive Pulmonary Disease (COPD)
24 million Americans have Chronic Obstructive Pulmonary Disease (COPD). Individuals with COPD are at risk of making multiple costly, stressful trips to the hospital. Research shows that many of these re-hospitalizations are potentially preventable through the use of proactive, team-based care coordination programs. HCFA is the only home care provider equipped with the expertise and passion to work with patients, families, and physicians to reduce the likelihood of hospital readmissions for individuals with COPD.
HCFA uses clinically proven methods to educate people with COPD and their families on the key aspects of the condition, how to monitor symptoms, properly use inhalers, improve wellness, and stay as healthy as possible.
The HCFA Care Coordinator and the HCFA team of condition-trained Certified Nursing Assistants and Home Health Aides make sure the:
- Patient clearly understands the plan of care from the physician and the steps needed to take to optimize their wellness
- Family feels confident their loved one can self-manage their condition
- Physician is kept up to date on the patient’s condition and made aware of any circumstances that may require attention
Three key components of the HCFA Care Coordination for COPD have been clinically proven independently to reduce readmissions in COPD patients:
- Proper inhaler use
- Smoking cessation
- Staying up to date on flu vaccines
Of those three components, nothing has a bigger impact on reducing negative outcomes than helping a person with COPD learn how to use their inhaler. Individuals with COPD rely on inhalers to deliver medications directly to the lungs. 80% of people with inhalers do not use them properly and are thus at risk of emergency room visits, hospitalizations, and hospital readmission. Patients using multiple inhalers are at the highest risk of hospitalization. A key component of HCFA Care Coordination for COPD is to educate the individuals on how to properly use their inhalers. It’s all about having help and peace of mind.
What happens during a HCFA COPD Care Coordination visit?
- Listen to the client’s and family’s concerns
- Understand: Gauge how well the individual and their family are coping with the diagnosis, oxygen therapy
- Nursing Assessment: Perform a focused physical assessment to evaluate respiratory status and oxygenation
- Go over: Physician orders, correct inhaler technique, appointment date and things to bring, and Plan of Care with Client and Family
HCFA CNAs and HHAs
- Check: Client’s vital signs, home safety, and food, medication, and equipment supplies
- Assist: Daily living activities, use of incentive spirometer, oxygen safety
- Review and Reassure: Plan for the day, maintain a helping attitude, remind the individual to use pursed-lip breathing
- Exit: Complete required paperwork, call the HCFA RN Care Coordinator with the update, and ask if they’ve met all needs
Heart Failure
Nearly 5 million Americans have heart failure, and 1.3 million of those people end up as a hospital readmission – in fact, heart failure has the highest readmission rate of all chronic diseases. Re-admissions are stressful for patients and their families, and they’re costly to hospitals.
Many of these return trips to the hospital can be prevented by the use of nurse-led care-coordination programs geared toward educating heart-failure patients and empowering them to self-manage their condition.
HCFA Care Coordination Program is an original program of its kind in the homecare industry, and it’s modeled after nationally recognized protocols that resulted in a 50% reduction in hospital readmission.
HCFA Care Coordination Program for Heart Failure focuses on educating heart-failure patients and working with them to manage the key aspects of the disease like:
- Medication and plan of care adherence
- Weight tracking
- Exercise, diet/nutrition
- Symptom monitoring
What happens during a HCFA Care Coordination Program for Heart Failure visit?
HCFA Registered Nurse will:
- Hear your concerns
- Evaluate your condition and Encourage you
- Assess signs and symptoms
- Review the plan of care with you and your family
- Teach you about heart failure and how to manage it
HCFA CNA or HHA will:
- Check weight; home safety; food, medication, and equipment supplies
- Assist with activities and exercise
- Review plan for the visit and reassure you
- Exit by asking if there’s anything else they can do for you or the family
Pneumonia
Nearly 1 in 5 people with pneumonia make costly, stressful return trips as a hospital readmission within the first 30 days of being diagnosed with the condition (www.medicare.gov). Individuals with pneumonia also are at a higher risk of having additional, underlying conditions that can make it more difficult to get better without assistance. Research shows that many of these re-hospitalizations are potentially preventable through the use of proactive, team-based care-coordination programs. HCFA is the only home care provider equipped with the expertise and passion to work with patients, families, and physicians to reduce the likelihood of hospital readmissions for individuals with pneumonia.
HCFA Care Coordination Program for Pneumonia uses clinically proven methods to educate people with pneumonia and their families on the key aspects of the condition and how to monitor symptoms, adhere to a plan of care, take their medication, improve wellness, and stay healthy.
The HCFA RN Care Coordinator and the HCFA team of specially trained Certified Nursing Assistants and Home Health Aides make sure the:
- Patient clearly understands the plan of care from the physician and takes the necessary steps needed to get better
- Family feels confident their loved one can self-manage their condition
- Physician is kept up to date on the patient’s condition and made aware of any circumstances that may require attention
The primary focus to improve the wellness of individuals with pneumonia is to make sure they take their antibiotics and that early signs of decline are addressed promptly. The HCFA Care Coordination Program team actively engages with a person with pneumonia through regular in-home visits and phone calls to make sure the individual takes their medicine and understands why it’s so important to do so. The HCFA team members are specially trained to look for and communicate key changes in symptoms to stay ahead of any potentially dangerous changes in an individual’s condition.
What happens during a HCFA Care Coordination Program Pneumonia visit?
HCFA RN Care Coordinator:
- Listen to the client’s and family’s concerns
- Understand their antibiotic regimen, and gauge how well the individual and their family are coping with the diagnosis, and understand
- Nursing Assessment: Perform a focused physical assessment with attention to respiratory system and oxygenation
- Go over: Physician orders, medications, appointment date and things to bring, and Plan of Care with Client and Family
HCFA CNAs and HHAs
- Check: Client’s vital signs, home safety, and food, medication, and equipment supplies
- Assist: Daily living activities, use of incentive spirometer if ordered
- Review and Reassure: Plan for the day, maintain a helping attitude, remind the individual to use pursed-lip breathing
- Exit: Complete required paperwork, call the HCFA Care Coordinator with an update, and ask if they’ve met all needs