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March 26. 2013 6:48PM

Anther View: How coordinated care can improve NH eldercare outcomes

One of the important challenges we face as a state and nation in implementing health-care reform is how we implement the concept of "coordinated care." It's a delivery model that forms the cornerstone of the Affordable Care Act of 2009. In a nutshell, the idea is to coordinate care that individuals receive from multiple members of the medical community so we can improve their care experience, produce better health and functional results and reduce Medicare and Medicaid costs.

When we are creating the care coordination delivery model, a good place to start will be with the care staff who best know the patient. How would this work?

A client of Lutheran Social Services is an 84-year-old retired teacher who has lived alone for 18 years, with a half-mile dirt driveway separating her from her neighbors. Fiercely independent and with no children nearby, she, like most of us, wants to remain at home. Until recently her only regular help was a home-care aide who assisted with grocery shopping, some cooking and cleaning for 10 hours per week.

Last year, she fell while at home and was hospitalized for treatment of five broken ribs and dehydration. She spent four days in the hospital and then four months in rehabilitation. Medicare paid the majority of her hospitalization and rehabilitation.

This year, her care and health status are closely coordinated by a home-care registered nurse. The RN reviews her health status and communicates with her physician when necessary. Upon the advice of the RN, she accepted six additional hours of home health care each week, sometimes twice per day.

Her nutritional status has improved; she has gained weight and now weighs 97 pounds. With additional monitoring by trained aides, who communicate with the RN who in turn communicates with her physician's office, she has avoided hospital readmission and additional Medicare costs.

This coordinated care and home care support is possible only because our client pays privately for her care. Currently, Medicare pays only for hospitalization and very short-term home care assistance following hospitalization. Medicare does not pay for her home assistance or the RN who supervises and coordinates her care. She is not Medicaid eligible, but even if she were Medicaid pays only for limited home care, and current reimbursement rates will not support RN oversight and coordination for persons receiving ongoing homecare assistance.

Effective care coordination will take place over time and will include the entire team of care providers. For older adults, the home care aide can play a crucial role in providing information about the client when health status declines or changes. No other paid member of the care system is present in the home on a regular basis and can implement the kind of proactive measures and monitoring of chronic conditions - congestive heart failure, diabetes, pulmonary disease and other conditions common in late maturity - that substantially reduce the cost to our public and private health coverage programs. Experienced home care aides are able to build a reliable and trusting relationship with their clients and family members and encourage healthy habits and safe living.

New Hampshire has more than 900 home-care aides providing thousands of hours of care in the homes of our Medicare and Medicaid recipients each year. New Hampshire would be well served to mobilize our existing home care workforce and include them in pilot programs being developed with funding from the Affordable Care Act as we move toward effective coordinated health care.


Rebecca Crosby Hutchinson is director of Lutheran Social Services in-home care, which provides home-care services to more than 400 clients throughout New Hampshire.


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