Suffering from kidney failure and other chronic ailments, Grace Arnold is the type of patient who typically bounces back and forth into hospitals.
But she managed to stay out of the hospital after her kidney failure thanks to a new program that partners Providence Hospitals with Right at Home, a non-medical in-home assistance company.
“It’s been unbelievable,” said Arnold, 86. “I can’t say how much help it was for me.”
The transition care program at Providence is part of a trend bringing care to the homes of people with chronic ailments. If you have congestive heart failure, these programs might allow you to stay in the comfort of home rather than in a hospital room. They might give you comfort that an elderly parent doesn’t need your help 24 hours a day. They also might reduce the cost of health care for everyone.
Most large hospitals have their own programs to supplement Medicare’s home health program for elderly patients. Specially trained Community Health Workers also operate out of the Eau Claire Cooperative Health Centers in Columbia through a federal grant and out of select primary care offices through a state Department of Health and Human Services program.
Each of the local programs is slightly different as health professionals look for the best solutions. The Providence/Right at Home effort, funded by a Duke Endowment grant, is the only one involving a private, non-medical assistance company. It mimics a similar program at Forsyth Medical Center in Winston-Salem, N.C., which showed a 65 percent reduction in hospital readmissions of high-risk patients.
Hospitals have extra incentives to make these types of programs work because Medicare has changed how it pays them. Hospitals get penalized $5,000 for every Medicare patient readmitted within 30 days of leaving the hospital.
Nationally, the 30-day readmission rate is about 25 percent. At Providence, the rate is about 22 percent, but it was below 10 percent (nine of 108) for patients in the first few months of the new program, according to Brittany Hudson, the Providence nurse navigator coordinating the effort.
Hudson is the coach of a team that includes the patient (and sometimes the patient’s family), the Medicare home health nurses and therapists and the non-medical workers with Right at Home. She talks with the patients first to determine their specific needs, then makes sure they get what they need – from prescriptions to in-home physical therapy sessions to groceries to fit a required diet.
“We’re all working to come up with a long-term plan,” Hudson said. “We’re a support system.”
For instance, the original dialysis facility Arnold was sent to was too far from her Columbia apartment. Hudson went to work and found an alternative closer to home. Mike Brown of Right at Home drove her to the dialysis appointments while working to get Medicare-approved transportation.
“He did my laundry, light housekeeping, helped me with grocery shopping,” Arnold said. “He took me to the doctor. He went to get my mail.”
Right at Home workers typically are in the patient’s home up to four hours a day for four to six weeks. In addition to the physical help, the workers try to lay groundwork for the patients to care for themselves.
“It’s a very complicated health care system,” said Charles Brown, owner of the local Right at Home franchise. “That’s part of the program, sorting these things out as much as you can with these fragile people.”
Arnold’s husband died 20 years ago. She has a son in Columbia, but he has a job and can’t give her 24-hour assistance. She has had hip replacements and back surgery. She needs to go to dialysis three times a week. She returned to the hospital as an outpatient three times in the process of determining the proper timing for her dialysis.
Despite her ailments, Arnold has a delightful demeanor. She charmed Brown, who continued to check in on her long after her six weeks of in-home care ended. She lets him know how much she appreciates the help.
“It was a wonderful thing in my life at a critical time,” she said.