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

Early results from the long-awaited study conducted by Harvard Medical School at the behest of private duty software developer ClearCare throw down a challenge to both payers and providers. The study was carried out by ClearCare customer Right at Home over the last three years.

Though Harvard researchers will not finish crunching the numbers and release the final results until later this summer at the earliest, Right at Home's VP for Franchise Business Solutions Mike Flair was able to discuss some meaningful preliminary findings at this week's Post Acute 360 conference in Washington DC.

Payers will discover solid evidence that in-home care can slash their overall costs, improve the health and attitude of their covered members and beneficiaries, and ultimately save them far more than their cost of reimbursing it.

Home care providers will discover that all of the above is only true when we are talking about excellent care, efficiently delivered, using software that directs caregivers toward the right number of visits or hours and facilitates complete and timely documentation.

One Typical Cost Avoid

Before getting into the details of how the study was conducted, Mr. Flair offered one representative anecdote that he said was repeated in one way or another throughout the project. A gentleman with diabetes was found by his home care aide to have a new open foot wound. She immediately called the patient's home health nurse, who performed an unscheduled extra visit that turned out to be four days before her next planned visit. The RN treated the wound and avoided an otherwise certain ER trip and likely hospital admission.

Organizing the Harvard Study

The three-year study followed an 18-month pilot, during which Harvard tested theories and interviewed franchise owners, care coordinators, and caregivers at 22 Right at Home locations. Once the pilot was completed, and reported in the Journal of American Geriatrics Society1, Right at Home recruited and trained willing franchise owners from 232 of its U.S. locations, bringing them into the study in four waves, adding one-fourth every six months.

During the pilot, 4,451 "Change in Condition" reports came in from caregivers over the course of 273,000 shifts for 2,391 clients, for a net 2 percent reporting rate. ClearCare facilitated reporting by providing a checklist that appeared on each caregiver's mobile device upon checkout at the end of a shift. It asked the non-skilled caregiver if he or she noticed any ADL, cognitive, or behavioral changes in the patient, such as energy level, eating and sleeping habits, speaking and hearing, and several similar non-clinical observations. They were not asked to diagnose, only to observe and report by checking boxes. As in the example above, care coordinators who viewed the reports decided whether an intervention was indicated.

Preliminary Results

Though Harvard is still working on producing a complete analysis, Flair was able to report on several raw measurements.

  • Patient hospitalizations over the course of the study were at 14 peercent
  • Non-medical caregivers reported feeling empowered and encouraged to observe and report patient conditions
  • Care coordinators were able to see field reports in real time without depending on casual conversations with caregivers if and when they came to the office, which is often only on payday

The study included:

  • 86 months
  • 8 million shifts
  • 14,000 unique clients
  • 45,000 Change in Condition reports

The established protocol was consistent across all Right at Home participating locations: 1) Caregiver observes and reports; 2)Care Coordinator contacts caregiver and client; 3) Care Coordinator contacts family and, as needed, other healthcare professionals.

Though CICs were reported 2 percent of the time in the pilot, the full study saw those reports drop to .5 percent. Flair reasoned that the caregivers grew more skilled in recognizing when a change is relevant and when it is not. He did not notice a decrease in completing the observation reports, only in reporting significant changes. The ClearCare software, Flair said, is fairly aggressive in reminding caregivers to complete the post-shift checklist.

Extensive training was provided to participating franchise owners through in-person sessions and online webinars. The training, he explained, centered around change management in order to deal with owners and staff "set in their ways," or who saw the study as a disruption to their routine. Those who were excited about working with Harvard Medical School researchers were recruited as project champions. They helped to inspire the group identified as being reluctant to change behaviors.

Harvard's final cost outcomes are due later this summer. They are comparing Right at Home outcomes to utilization and spending with publicly available Medicare claims numbers.


1 Preliminary Data on a Care Coordination Program for Home Care Recipients
Journal of the American Geriatrics Society, Volume 64, Issue 9, First published: 10 August 2016
(See Sidebar for JAGS executive summary)

  • Katie M. Dean
  • Laura A. Hatfield
  • Anupam B. Jena
  • David Cristman
  • Michael Flair
  • Kylie Kator
  • Geoffrey Nudd
  • David C. Grabowski


Executive Summary

Home care recipients are often hospitalized for potentially avoidable reasons. A pilot program (Intervention in Home Care to Improve Health Outcomes (In-Home)) was designed to help home care providers identify acute clinical changes in condition and then manage the condition in the home and thereby avoid a costly hospitalization. Caregivers answer simple questions about the care recipient's condition during a telephone-based “clock-out” at the end of each shift. Responses are electronically captured in the agency management software that caregivers use to “clock-in,” manage care, and “clock-out” on every shift. These are transmitted to the agency's care manager, who follows up on the change in condition and escalates appropriately. A description of the In-Home model is presented, and pilot data from 22 home care offices are reported. In the pilot, caregivers reported a change in condition after 2% of all shifts, representing an average of 1.9 changes per care recipient in a 6-month period. Changes in behavior and skin condition were the most frequently recorded domains. Interviews with participating caregivers and care managers suggested positive attitudes regarding the intervention; challenges included resistance to change on the part of home care staff and difficulties in applying a uniform intervention to individuals with varying needs in home care offices with varying capacities. In an ongoing randomized trial, the success of the overall program will be measured primarily according to the potential reduction in avoidable hospitalizations of home care recipients and the effect this potential reduction has on spending and healthcare outcomes.

©2018 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.