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How home health and community-based services are positioned as integrated partners.

Interview with Paula Thompson, RN, MS, CRNI, President and CEO of Fidelity Health Care in Dayton, Ohio.

“Home health agencies need to find their role in the digital future of health care.  Being able to engage patients and promote self-care, using tools and techniques that keep patients in their home and independent, will satisfy patients and providers in the future.”

– Paula Thompson

Remington Report: Paula, thank-you for taking the time to respond to this interview during this very difficult time of COVID-19. I appreciate you sharing with your peers how post-acute providers can navigate challenges and demonstrate their value.

Fidelity Health Care is the home and community based service and product provider of Premier Health in Ohio. Services include Home Health, DME/Respiratory, Infusion, wellness based services and products, focused on consumers, employers and schools.

Fidelity Health Care has diligently been aligning clinical programs with your five-hospital health system and physician practices over many years. The challenges presented by COVID-19, has your organization positioned to respond as a key partner. Let’s dig-in to how your organization’s proactive approach is working to align solutions with your health systems and physicians.

Fidelity Health Care’s Care Management Center for Premier Health is the comprehensive provision of services that ensures the cross-continuum plan of treatment for individuals. The Center facilitates in the most high quality and cost effective manner. Can you describe how the Center works and how it is beneficial under COVID-19?

Thompson: Having the Care Management Center infrastructure in place has allowed the team to integrate within several areas across the health system to assist with its response to the COVID-19 epidemic.

The Center was originally established to perform transitions of care services, for hospital discharge patients, at risk for readmission.  The team has a structure of service it delivers, once a patient is identified as high risk.  Specific scripting directs the team through a telephonic outreach at day 2 and day 14.  Assessment, medication reconciliation and treatment review, provides assurance that the patient understands their treatment plan, identifies any barriers, and is scheduled for their post-discharge follow-up appointment.  The number of patients contacted prior to the pandemic was approximately 800 per week.

With the orders from the Governor of Ohio to stay at home, fewer patients were able to follow-up with their PCPs after discharge.  Like other hospitals, our system was facing preparation for a surge of patients with the virus. The Center team saw a dramatic reduction in patients discharged from the hospital, as elective surgeries were cancelled, and virus surge preparations were underway.   With the excess capacity, the team was available to serve patients in other ways.

The chronic care patients, normally seen by their PCP, were now all at high risk.  With physician office visits moving to digital and email, our team was able to use their outreach skills to assist in monitoring those patients for follow-up and facilitate patient visits with a video or email outreach to their PCP, as needed.  The sophistication of our outreach team was not just used for the discharge patients, all COVID positive or COVID pending patients were automatically placed on a high-risk list to receive outreach and follow-up to reduce the risk of readmission or a visit to the ED.

Employee health was overwhelmed by the number of health care workers that were potentially exposed and pending test results.  Since the Center team was already managing the chronic care, high-risk employees and the 24/7 nurse line for the health plan, it was an easy transition for them to engage the employees, facilitate education, follow-up, and assist with communication, in order to get these employees well and back to work, as soon as possible.

Remington Report: Fidelity Health Care has been successful developing and implementing telephone management. This is a 24/7 medical answering service to assist physician office after hour calls, a paraprofessional answering service and a clinical nurse line. How has this model been an important solution under COVID-19?

Thompson: During this crisis, the physicians and providers are only seeing patients face to face, as needed. The offices were receiving a tremendous number of calls regarding appointments and follow-up.  Our operators and nursing staff were able to step in and manage the increased number of calls and facilitate messages and communication to the provider on-call.  The nursing team, who manages the afterhours call for about 115 primary care and specialty practices, was able to triage, engage patients, provide resources for their questions and concerns, and hopefully allay fears, in an attempt to keep patients at home and out to the ED and hospital, as appropriate.

Remington Report: A key focus of your home health division is chronic care management. Fidelity has a very robust transitional care management model important to physician practices. How is this helping in the discharge planning process and with physician practices?

Thompson: The Care Management team has developed and implemented a robust chronic care management program for high and rising risk patients discharged, from our hospitals or identified by physicians in the community.  These patients are enrolled and engaged by the Care Management team.  A structured protocol directs the team to work with the patients to promote management of their disease process and ensure that exacerbation of illness is identified early, and intervention is provided quickly.

The Center team has recently been allowed to schedule directly into the physician’s schedule.  This process has allowed the team to schedule the patients prior to discharge from the hospital, and ensure patients are eligible for a Transitional Care Management (TCM) visit from the physician, meeting the timeframe required.  In coordination with the physician’s practice, the Care Center team is scheduling visits, in a centrally based community clinic, for patients who have been diagnosed with the COVID-19 virus. This will dramatically reduce the need for PPE and provide a consistent and standardized process of care for these patients.

If the patient is unable to travel and visit their physician in the office, the home health team will assist in scheduling the facilitation a video visit with the physician.

Any patient with COVID-19 and co-morbid conditions, may be eligible for the Chronic Care Management program.  This program engages patients and provides care management for those with high risk for 16 weeks and 12 weeks for rising risk.

For Care Transitions and the Transitional Care Management program, the Care Management team initiates a phone call to the patient within 48 hours, documents the patients understanding of their discharge orders, performs the medication reconciliation, and ensures the patient is scheduled for an appointment with their PCP.

Remington Report: Describe your digital-based patient engagement program. How has this solution benefited during COVID-19?

Thompson: The Care Management Center manages two separate systems of digital based patient engagement. One system is called Get Well Loop.  This digital outreach tool is used to engage patients at low risk for rehospitalization or who have experienced an ED visit.  An email or text, patient’s choice, is sent to the patient within 48 hours and then weekly to provide engagement, interaction, education and information based on the patient’s response to a simple series of questions.  If a patient triggers a “red flag” answer, this could identify potential decline or an exacerbation of their disease process.  A “red flag” would stimulate a report for our nursing team and a nursing outreach call will occur.

The second tool used is telehealth. This tool is provided to selected patients that are at high risk for readmission to the hospital.  Primarily, this tool is used on patients diagnosed with COPD and or CHF.  They are managed by the Chronic Disease Managers in the Care Center for follow-up, engagement, and the promotion for self-management of their disease process.

Remington Report: How do you see the future of home health expanding to demonstrate further value to health systems and physicians?

Thompson: I see a very bright future for home health agencies, who can be flexible, nimble and provide a valuable service to hospitals and physicians practices, which will lead them into the future of value-based care for patients. When the services are focused in the community and outside of the hospital, systems can dramatically lower cost of care and promote better management of patients by using experts that understand and can manage patients in that arena.

Home health agencies need to find their role in the digital future of health care.  Being able to engage patients and promote self-care, using tools and techniques that keep patients in their home and independent, will satisfy patients and providers in the future.

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