Serving the home health, home care and hospice industry since 1999.

Welcome to the future!

Thanks to the Affordable Care Act of 2010 (ACA) and resulting rules that will impose cash penalties on hospitals unable to control readmission rates, relationships between hospitals and all post-acute providers will change when Federal Fiscal Year 2013 begins on October 1, 2012.

As we speculated last month (HCTR July 27, "Futurists Present To-Do List to Home Health Care Providers Hoping to Survive Healthcare Reform"), networks of post-acute providers will begin to appear so that coordinated care efforts by a team of case managers and discharge planners can place patients in the most effective locale for their needs. We found just such a network and its early impact on local hospital readmission rates underscores our July prediction.

In addition to home health care agencies, the Community Health Initiative Network (CHIN) includes skilled nursing facilities, long term care institutions, hospice and palliative care providers, rehab hospitals, home medical equipment companies, assisted living facilities and group homes. Care is coordinated by case managers, who are responsible to patients first, payers second and care providers third as they go about deciding the least costly care location that can meet each patient's preference while best seeing to their care requirements.

We spoke with the CHIN Executive Director to see what the future of post-acute care will look like.

Janet Wheble, MPAS, P.A.-C, is a Physician Assistant who specializes in geriatrics. She and a friend who owns a home medical equipment company created CHIN, which serves patients in and around Las Vegas, Nevada. What CHIN is doing is what all post-acute providers will be doing in less than two years. Here are the highlights:


  • In its first eight months, dozens of care providers have joined as members of the network, including all of the providers types listed above.

  • The network accepts patients who are most at-risk for hospital readmission.

  • A nurse acting as Care Coordinator manages plans of care and assigns each patient to a care
    location. If it is appropriate for their needs, patients go to the location of their choice.

  • Care Coordinator's first loyalty is to the patient, considering comfort, care needs and outcomes. Second consideration is to the payer, third to each healthcare provider within the network.

  • Coordination and patient education begins in the hospital, before discharge.

  • Origins: Wheble pitched the concept to twelve local hospitals. One agreed to a 90-day pilot, serving only CHF and COPD patients. After 90 days of no readmissions whatsoever, the hospital insisted on expanding to its five other locations. Today, all twelve area hospitals participate and patients with all types of chronic conditions are accepted.

  • Patients are tracked by the network for 90 days after hospital discharge, making sure they go to all appointments, follow their care plan and diet, take their medications as prescribed and know about all relevant community services they would previously have had to seek out on their own.

  • In its first eight months, the network has served approximately 100 patients and only one was readmitted to the hospital. It was for a procedure unrelated to the patient's chronic condition. A handful have expired, but all of those deaths were expected and occurred in comfort, under the care of hospice nurses.

  • Currently, Care Coordinators are employed by various members of the network.

Technology Selection GuideIt is not about the money, at least not yet
Ms. Wheble told us the network is not yet generating enough revenue to pay a staff, including herself, but that a grant she has applied for may change that. In the future, hospitals and payers may be convinced of the wisdom of sharing with the network savings that accrue to them from significant readmission reductions. Pursuing that sales pitch is on her agenda for the future, after more data has been gathered and analyzed.

"None of our participating members joined the network for any reason other than a desire to improve patient care," the Director told HCTR. "We did have some who thought participation would increase their revenue but they ended their network membership when that did not happen. We were happy to see them go back to serving a relatively healthier and more profitable patient population. Every participant that remains in the network is committed first and foremost to providing quality patient care and to improving patient experiences."


1. Home Telehealth
A large contributor to Community Health Initiative Network's drastic readmission reductions is its reliance on remote patient monitoring systems. Network members, especially home care and hospice providers, have access to the services of Fusion Care Systems (FCS). The Las Vegas company's turnkey patient monitoring services and call center remove from the home care and hospice company the burden of purchasing, installing, removing and sterilizing home telehealth devices. In addition, it gives them a menu of technologies that can be mixed and matched to meet unique patient needs.

According to company founder Matt Smith, FCS installs systems in a patient's home, an assisted living facility or a group home. Options include traditional desktop home telehealth vital sign monitors, with or without two-way patient communication systems, electronic medication dispensers, and passive monitors such as bed weight sensors, motion detectors and sensors that indicate opening and closing of refrigerator or food pantry doors.

"One of the obstacles to deploying home telehealth systems is not only the initial investment but the risk that a unit will sit on a shelf gathering dust or become obsolete," Smith told us. "If the home care agency owns it, they are stuck with it. With a turnkey service provider, they rarely if ever see the unit. We deliver it to the home, remove it when it is time and clean it between uses. When a more modern technology becomes available, we add it to our fleet."

Smith also described how the FCS call center service helps control hospital readmissions. "In the middle of the night, when a CHF or COPD patient might become distressed and otherwise call 911, they call us and we triage the situation. Their personal priority list might include a home health care on-call nurse, a relative or a next door neighbor. Depending on their condition, we call the appropriate person to intervene. When someone has to call 911, a hospital admission is almost inevitable."

2. Patient Education
Acknowledging the significant contribution of technology, Janet Wheble puts her faith in the positive effects of patient education. "The number one reason this network of post-acute providers has virtually eliminated hospital readmissions among the most at-risk patients with chronic conditions is because our members partner with their patients. We start in the hospital, educating them both about their medication regimen and the activities for which we expect them to take responsibility, such as diet, exercise and keeping appointments. Anyone who expects to duplicate what we are doing in their own area must begin with the axiom that patient education is the key."

Anyone who wants to duplicate CHIN is welcome to contact Janet Wheble and Matt Smith. Even though their experience with this project is less than a year old, it is easy to see from their early results that they have something of value to offer.

Editor's note: Matt Smith can be found on the web at Janet Wheble's contact information is available by writing to us: