According to the American Geriatric Society, 62% of all hospital readmissions for seniors are preventable.

The top four risks for senior readmissions according to the National Institute of Healthcare Compliance are:

  • falling,
  • medication adherence,
  • nutrition/dehydration, and
  • patient discharge compliance.

Learn how your peers are innovating and expanding care at home services to reduce readmissions and expand collaborative partnerships.

Leveraging Technological Advances to Manage Complex Conditions

How the Visiting Nurse Service of New York (VNSNY) is Revolutionizing Home-Based Care Management and Expanding Collaborative Partnerships

The ongoing evolution of home-based health care technology goes well beyond new medication protocols. It includes ongoing innovations in care delivery — such as telehealth monitoring, clinical support software, and data analytics — as well as increasingly sophisticated partnerships between home- and community-based care providers and local physician and hospital groups. These developments are reinforced by new reimbursement models that encourage increased caregiver-patient communication and enhanced care coordination among medical providers.

To give you an idea of how these advances are changing the health care landscape, here are some of the ways that VNSNY — which operates a certified home health care agency as well as an insurance division that services Medicare and Medicaid recipients — is leveraging innovation to deliver state-of-the-art home-based care to their patients and plan members:

  1. Care Management Software and Population Health Algorithms

Using customized platforms developed by their Care Management/Population Health and our Outcomes departments, VNSNY synchronizes the electronic medical records of VNSNY’s home care patients and plan members’ data to software programmed with state-of-the-art diagnostic and treatment algorithms. In addition to ensuring that their care managers have a complete clinical picture of every patient, these interconnected platforms help guide clinicians in determining what tests and interventions to administer by generating evidence-based clinical pathways and protocols tailored to each patient’s medical status.

  1. Smartphone Apps for Home Health Aides

VNSNY is empowering home health aides to serve as “eyes and ears” for clinicians by supplying them with smartphone apps that allow the aides to record their client notes digitally on their phones, including any troubling signs or symptoms they may have noticed, and then send these notes directly to clinical care managers.

  1. Remote Monitoring: High-Precision Telemedicine Devices

For patients whose daily symptoms require close monitoring, VNSNY now routinely use a range of high-precision telemedicine devices, including in-home blood pressure cuffs, finger clips that record heart rate and blood oxygen levels, a device that measures blood glucose levels in patients with diabetes, and a digital scale for assessing weight gain in heart failure patients. These measurements are transmitted automatically from the patient’s home to a central data bank where abnormal readings are flagged, triggering a nurse’s visit to the patient’s home — thereby avoiding hospitalizations due to unattended symptoms that have raced out of control.

VNSNY is utilizing customized care management programs to identify which of their patients and plan members are at highest risk of complications and require the closest monitoring.

  1. Hospice: Stored Medical Instructions

VNSNY’s hospice program is pioneering the use of digitally stored medical instructions for hospice patients that can be readily accessed by any care provider, avoiding the use of extraordinary measures that the hospice patient and their family have already explicitly vetoed.

These technologies enhance their ability to deliver home care consistently and effectively, and are also facilitating partnerships with other providers — again, preventing complications and related hospitalizations that might otherwise occur due to gaps in care coordination.

One of the most important ways VNSNY is bringing medical care into the home is by leveraging innovative technologies in collaboration with other care providers at the community and hospital level. For example:

  1. Health Plans: Improved Communication

VNSNY is working to improve the exchange of digital health information with the primary-care providers of their CHOICE Health Plan members to ensure better care coordination.

  1. Paramedics: Chronically Ill Patients Teleconference

VNSNY is teaming with the Mount Sinai Health System to implement a program in which their electronic health records system directs care coordinators to send specially trained paramedics to the homes of chronically ill patients, if and when they exhibit symptoms that might ordinarily prompt a 911 call and a trip to the hospital. Instead, the paramedic sets up a teleconference at the patient’s bedside with a VNSNY clinician and a Mount Sinai doctor, then provides in-home emergency care based on their instructions.

  1. Palliative Care Hospital-at-Home Partnership

VNSNY is collaborating with Mount Sinai on a cutting-edge in-home palliative care initiative for non-hospice patients as well as a “Hospital at Home” program, in which our nurses provide hospital-level acute care in the patient’s residence under the supervision of a Mount Sinai physician.

  1. Clinicians: Specialized Cardiac Training

A number of VNSNY’s nurses have received specialized training from clinicians with New York­–Presbyterian Medical Center’s Ventricular Assistive Device (VAD) program on how to care for their patients’ heart pumps at home after they’ve been discharged. As a result, VAD patients who once lingered for months in the hospital can now return to their families, knowing they’re in good hands with their home care clinicians.

There’s a common theme to these innovative approaches: They all leverage technological advances to manage complex conditions directly in the patient’s home, thereby preventing or addressing problems that could otherwise lead to hospital admissions. By enabling VNSNY to manage people’s conditions at home in a comprehensive, cost-effective fashion, these innovations are reducing health care expenditures significantly while also helping millions of Americans avoid the stress, medical risks, and disruption of a hospital stay.

As their home-based capabilities continue to advance, these innovative home health care approaches are emerging as the care delivery model of the future.

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