Consider Home Care After Patient Hospitalization

There’s no place like home. That saying is especially true for older adults who say they prefer to receive care at home. According to a recent study by AARP, when asked about their care preferences, Americans over age 50 overwhelmingly expressed a desire to age in place and receive care at home as opposed to institutional settings. If medically appropriate, recovering at home can be a good alternative to lengthy hospital stays or a skilled nursing facility.

“Patients are becoming increasingly engaged with their care, and we strive to empower them. We recognize that recovering at home following an injury or illness gives patients greater control and promotes quicker progression toward recovery,” says Laura Kohler, administrator, integrated care coordination, Lehigh Valley Health Network (LVHN).

The hospital is the best place for those who need around-the-clock care. But for those who only need intermittent care, recovering at home offers several advantages.

“Home health offers an optimal opportunity to identify and respond to the needs of individual patients and families. Care decisions are made and managed ‘around the kitchen table,’ which often makes patients more comfortable,” Kohler says.

In addition to higher patient satisfaction, home health care can be a safer alternative for older adults. Patients are less likely to contract infections or other illnesses at home than at a hospital or skilled nursing facility. Home health outcomes also show lower mortality rates, lower readmission rates and improved activities of daily living.

For those eligible to receive care at home, LVHN has several resources available. Kohler says the programs were designed with home health in mind.

• Acute Care Bridge Clinic (ACBC) – The goal of ACBC is to help bridge the transition from the hospital to home. The team of care navigators collaborates with specialists to provide immediate followup care virtually through a video visit after individuals are discharged from the hospital. Care navigators can help manage questions regarding medications, follow-up visits and more.

• Remote patient monitoring (RPM) – RPM helps individuals with chronic conditions learn to manage their health from home. Those placed in the program receive a kit that includes tools to record their vital signs. Information is reviewed by a member of the RPM team, and if needed, they will reach out to discuss any concerns or pass along the information to the person’s care team for further review. Patients usually stay in this program for about 90 days.

• LVHN@Home – LVHN@Home combines home nurse visits, virtual physician visits and enhanced remote patient monitoring to help those who may need to be monitored but not necessarily hospitalized. Individuals in the program receive a kit that includes tools to record their vital signs. Information is reviewed by a member of the RPM team who coordinates care between home care and the ACBC. The ACBC will see individuals via video, as needed, throughout the program. Patients usually stay in this program for two or fewer weeks.

• Transition of care and care navigation – Transition of care team members are available to help individuals following their discharge from the hospital. For those eligible, a transition of care team member may provide care coordination services for 30 days after discharge