A Solution for the Frail Elderly Population

In 2014, Medicare fined a record 2,610 hospitals (out of 3,353 subject to the Hospital Readmission
Program) an estimated $428 million in penalties for having high readmission rates for certain diagnoses
(i.e. heart failure, heart attack, pneumonia, knee or hip replacement, and lung ailments).
In 2013, nearly 18 percent of Medicare patients who had been hospitalized for one of five conditions
studied was readmitted within 30 days of hospital discharge, according to Kaiser Health News. Roughly,
2 million patients return a year, costing Medicare, $26 billion. $17 billion of that expense comes from
potentially avoidable readmission.
WHAT ARE WE DOING TO DECREASE THAT NUMBER?
TLC HomeCare is an Upper Valley, New Hampshire & Vermont, home care organization providing
services for patients being discharged from 4 community hospitals, a large VA Medical Center, and
Dartmouth-Hitchcock Medical Center (a tertiary care center in the midst of it all). The Upper Valley of
New England is in the center of New Hampshire and Vermont, and TLC HomeCare has a service area in
both states.
Most of the patients/clients discussed above share many common similarities; most are above the age
of 65, most have co-morbidities (multiple diagnoses), and polypharmacy (multiple prescriptions). Many
do not have adequate support systems in place in an area that is very rural in nature. Some of these
patients/clients, have skilled nursing needs at the time of discharge, and those services will be covered
under the Medicare benefit for Visiting Nurse services. Examples of skilled nursing are; catheter
changes, wound dressing changes, IV drug administration, ect.. But a large number of these discharged
patients/clients do not have a skilled nursing need and therefore do not qualify for Medicare
reimbursement for visiting nurses. This is the population that is at the highest risk of non-compliance
and potential readmission stemming from complications. It is also the population that TLC HomeCare is
most concerned about. TLC is actively discussing with its partner hospitals, its integration into a care
transition program for that population that does not qualify for the Medicare benefit but have a need to
provide assistance to the patient and the family in the management of the first 30-90 days of discharge
care coordination.
TLC HomeCare uses a service model that provides nursing oversight for all of their patients/clients. The
initial assessment after discharge is done by a RN (registered nurse) case manager, who completes a
complete physical and cognitive assessment and designs a care plan that is followed by the caregivers in
the patient/client home. The longitudinal care is provided by LNAs, CNAs and PCAs. In this way, TLC
HomeCare can keep the costs of services at a more reasonable rate, while still providing RN Case
Management for all of its clients. Examples of non-skilled nursing services are; medication reminders,
assistance with bathing and dressing, light housekeeping, laundry and meal preparation.

Among the techniques used to reduce readmission rates has been the inclusion of a timely follow-up
visit with a primary care physician. At these appointments, discharge directions can be reinforced,
medications reviewed, lingering issues addressed, and questions answered. If needed, at that time, care
plans can be revised. TLC HomeCare, will also provide transportation and companionship to these
important follow-up appointments at the doctors office or the hospital.
At the present time, these services are not covered by Medicare, and are paid by either long term care
insurance or out-of-pocket by clients or their families. With an aging US population, the hope is that
over time, the importance of the longitudinal post discharge services provided by TLC HomeCare will be
fully integrated into the care coordination of this frail elderly population.