Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Thinking Differentlyabout Hospital

ReadmissionsLaNita Knoke RN, BS, CMCN Healthcare Strategist

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Senior Care Continuum

Family Caregiv

er

Primary Care Speciali

stsHospital

sHospice

Home Care

Home Health

Physical/Occupational

Therapy (other needs)

Rehab Family Caregiv

er

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Nutrition Medication Management

Doctor Appointmen

ts

Warning Signs

Four Areas of Focus

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Knowledge

Compliance

Meeting Basic Need

Personal Side of CareKnowledge

Compliance

Com

munic

ati

on

Com

munica

ti

on

BASIC NEEDS

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Home Instead Re-Admissions Studies

2

Livonia, MI

Richmond,VA

1

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Desired Outcome

2

1

Both Studies were designed to determine if patient compliance with discharge instructions along with monitoring of key quality outcome indicators in the home, correlated to reduced unnecessary hospital readmissions

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Study May 1, 2012 – April 1, 2013

Large for profit hospital system

1

GOAL: Reduce hospital readmissions of 16% by 1%

55 patient

pilot study

Primary diagnosis: CHF (Heart Failure)

30 DayPlan of Care

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Study July 2012 to November 2012

2 non- profit hospitals

2

GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance

30 patient

pilot study

Primary diagnosis: CHF (Heart

Failure)/COPD

30 DayPlan of Care

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Discharge Model

Example

1

2

3

4

Discharge Planners completed risk assessments on each patient

Home Instead Senior Care completed care consultations to determine patient specific home needs prior to discharge With the Discharge Planner, and based on these assessments, we determined the necessary level of care, which drove the required hours of care

Prior to discharge we worked together to created Individualized Care plans that involved the patients own goals

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

• Care Plan focused on patient-centered goals with action plans– Functional goals: drive, grocery shop, wedding, garden

• Home Instead Senior Care was present at discharge– Helped to build trust, clarify discharge instructions, and

understand the programWeek 1: one hour of

service for five visits

Week 2: one hour of

service for four visits

Week 3: one hour of

service for three visits

Week 4: one hour of

service for one or two

visits

Home Management with Patient

Employment of a Teach Back Methodology instead of a complete care approach

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Patients only remember and understand <50% of what clinicians explain to them in a hospital setting

Patient Education

Patient Engageme

nt

The discharge plans must shift

from to

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

– Medication management reconciliation from discharge

– Appointment with Primary Care Physician first week home

– Diet and Nutrition low salt

– Monitoring vital signs blood pressure, weight, fluid intake

– Warning signs red flags – red, yellow, green zones

– Organization of medical records in the home

Critical Components for Success

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

OutcomesStudy

1

23.5%

in readmission rate. Initial goal

was to drop it 1%

Reduction

97%

Upon national readmission estimates for

Medicare patients with CHF

Improvement

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

OutcomesStudy

2

96%

93%

90%

Of patients were discharged to their own homes

Of patients remained out of the hospital 30 days post discharge

Of patients remained out of the hospital 90 day post discharge

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

OutcomesIn both studies we were able to fill the discharge gap in education and compliance.

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Follow-Up Physician

Visit Assistance

Nutrition Manageme

nt

Warning Signs

Monitoring and

Notification

Medication Self

Management

Care Management with Patient

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Best Practice Results

• Ensuring nutritious Groceries are in the home, reviewing the hospital diet instructions and providing mealtime socialization

• Physician appointment within 7 days post discharge, testing and therapy follow up completed when scheduled by providing transportation and assistance

Disciplined, consistent

discharge process

Successful hospital to home

transition

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Results (Cont.)

• Teaching patients to care for themselves instead of doing the care for them

• Developing the Returning Home Program

• Focusing on initial Admission Prevention

• Medication Management needs resulted in launching Simple Meds by Home Instead

Each Home Instead Senior Care franchise office is independently owned and operated.

Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.Each Home Instead Senior Care® franchise office is independently owned and operated. © Home Instead, Inc. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.

Person-centered solutions to reduce hospital readmissions