The Continuum of Care: Hospital to Home and KPOC’s Strategic Home Health Plan

There are 77 million baby boomers in the United States, and 10,000 of them turn 65 each day. In the future hospitals or nursing homes may no longer be the only options. In the months and years to come, the home health care industry will become the solution for many as our aging population requires more care.

Numerous forces are pushing care away from nursing homes and driving it toward home- and community-based care. Baby boomers won’t put up with being warehoused in nursing homes and lose their freedom when they need chronic or long-term care. Home health and hospice are driving much of the investment in health services as Americans turn away from nursing home care.

Home health care is key player in successful patient-centered medical homes and in accountable care organization models.

Throughout the United States, the Home Health industry is being held up by policy makers as an ideal cost-effective solution to rising medical costs and hospital readmissions. The critical point is to get more resources and money into home- and community-based care so agencies so that providers can invest in the technology and software that will increase the quality of care for patients in the home health environment.

At Kaiser Permanente our home health team has implemented a strategy that is taking all the above into consideration as we plan for the future of our member’s needs. Four opportunity areas have been identified.

• Internal Productivity 1. Inter 1. Internalductivity

• Data Analytics

• Governance/Compliance/Regulatory

• Outsource Capability

• Transformative

Other important considerations include patient centricity, connectivity, high quality, technology.

1. Patient-centered. The future will put the patient and his or her needs and goals foremost, developing care plans accordingly.

2. Connected. Promote improved collaboration and communication amongst staff and providers to enhance internal productivity and patient satisfaction.

Our teams need to connect in new ways with our medical centers, physicians, skilled nursing facilities, and others, be it through technology, improved communication/handoff and department agreements.

Connectivity needs to happen at every level to make our processes and work flows less wasteful, and a better, less fragmented experience for our members.

3. High quality. When we outsource cases we want to partner only with other best-in-class organizations. A focus on quality is the key to our success in the future.

This means adhering to evidence-based best practices, and leveraging all the data and analytics capabilities that are becoming increasingly available and sophisticated, to drive continuous quality improvement.

4. Tech-enabled. Technology will undergird efforts in nearly every realm of home health in the future. Connections with other providers will be facilitated with health information exchange and care coordination supported by mobile and digital tech. A particular priority should be using technology between home health in-person encounters with education, messaging, video encounters.