As we’re aware, the majority of our home health care patients are elderly with multiple chronic and progressive medical conditions including congestive heart failure and COPD.  These serious chronic illnesses are associated with high rates of distressing symptoms, disability, frequent hospitalizations, and increased mortality.

Heart failure (HF) is a prime example of how current healthcare models fall short in providing care for older chronically ill patients. As with many chronic progressive diseases, the majority of deaths from advanced HF are preceded by a period of worsening symptoms, functional decline, and increased use of healthcare services.  In-hospital mortality rates have significantly improved in the last 10 years, but our traditional system falls apart once patients are discharged.  Elderly HF patients have a 1 in 4 chance of being re-hospitalized and a 1 in 10 chance of dying within 30 days of discharge from the hospital. Many of those re-hospitalized did not even see a physician after their initial discharge.

Adding comprehensive and interdisciplinary post-discharge support for older patients with advanced illnesses can significantly reduce readmission rates and improve quality of life and functional status. Post discharge support for older persons with HF has been shown to reduce the risk of readmission, improve quality of life scores, and potentially reduce mortality.

Home hospice is an important component in providing high quality post-discharge support and palliative care. However, its use may be limited when caring for patients with advanced chronic illnesses (like HF) because patients may still be focused on treatment for their disease, the trajectory of the illness maybe be variable, and hospice staff may not be adequately trained in managing non-cancer diagnoses (see recent article). This is where home care agencies have the power to make significant change! Innovative comprehensive home care programs can help fill this gap by integrating the palliation of symptoms, care coordination, and advance care planning earlier in the disease trajectory of patients with advanced illnesses.

One such innovative model is the Advanced Illness Management (AIM), a home-based palliative care program. [Click here to see CHAMP’s Framework Brief on Palliative Care and AIM.] AIM programs provide a blend of disease modifying and comfort care interventions, acting as a bridge between hospitalization and hospice. The care is adjusted to meet patient’s needs when their illness progresses and as their goals shift more towards supportive care.  Helen Kao, a Home Care Physician and part of the Division of Geriatrics at UCSF, describes one of the main benefits in working with AIM programs as the increased attention paid towards advanced care planning and a more open discussion about prognosis as these chronic diseases progress. These discussions can help transition patients to more traditional hospice care at the end of their lives.

Programs like AIM are much more aligned to the needs of chronically ill elderly than traditional models designed to treat short term acute illnesses. Dr. Brad Stuart, Senior Medical Director at Sutter VNA & Hospice and a leader in AIM, believes that if home health steps up to the plate, they could act as a major player in re-engineering traditional acute care-focused models like Medicare. As Dr. Stuart recently told me, “home care can serve as the glue that binds together the disparate silos of Medicare reimbursement.”

The possibilities are exciting, but challenges exist to delivering care more reflective of the needs of the chronically ill elderly. Medicare’s regulations and reimbursement structure creates incentives for home care agencies to quickly discharge patients, limiting the amount of contiguous care that they can provide.  Dr. Stuart argues that for innovative programs like AIM to really take root, some type of payment system reform is necessary. Will home health care take the lead in creating this change?

Eric Widera, M.D.
Assistant Clinical Professor, Division of Geriatrics, UCSF
Associate Program Director, Geriatrics Fellowship, UCSF
Director, Hospice & Palliative Care, San Francisco VAMC