A growing focus in healthcare delivery is providing a longitudinal, patient-centered approach to care with more coordinated and accessible care across their entire healthcare journey. Importantly, when a patient has been diagnosed with a serious chronic condition or even as they progress through the natural aging process, the need for a cohesive continuum of care becomes critical.
The continuum of care should evolve with the patient over time, ensuring that their most vulnerable care needs are filled throughout health and life transitions. It also should be accessible and available in the least restrictive way possible — making the home a perfect setting for receiving care across the continuum.
Having a range of health services under one umbrella allows a seamless and more accessible transition for your patients to enter different types of care. This is why Amedisys brings home health, palliative care and hospice to patients where they most want to receive care— in their own homes.
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Benefits of a Strong Continuum of Care
The challenges caused by healthcare fragmentation are well known to both patients and providers. All too often, as patients face complex and chronic illness, gaps in care appear as they move between various providers and locations of care and communication potentially breaks down.
This lack of coordinated care contributes to adverse patient outcomes including increased healthcare costs, higher rates of emergency department visits and unnecessary testing and treatment.
It’s important to consider how a strong continuum of care delivery at home can enhance care, improve relationships and increase efficiency for all stakeholders.
How Does Amedisys Support a Stronger Continuum of Care?
Patients facing chronic conditions and at risk for frequent hospitalizations require an additional level of support. In these cases, a provider may refer eligible patients for home health care, hospice or palliative care if appropriate. This is often an opportunity to improve patients’ care outside of routine appointments and acute episodes of care.
However, without a consistent thread weaving together these experiences as patients’ needs change, a referral to home health, hospice or palliative care has the potential to become another piece of the fragmented healthcare puzzle.
At Amedisys, our large national footprint and comprehensive care offerings across the home care continuum allow us to connect the dots on a patient’s journey through a chronic or serious illness.
Home Health in the Continuum of Care
Home health care offers an opportunity for patients to receive care without the typical barriers of travel and limited mobility that can make it difficult for some patients to access healthcare services. Bringing care home increases patient and family engagement in managing chronic health concerns and can often be the entry point to other services provided in the at-home care continuum.
Amedisys partners with healthcare providers to bring our team of RNs, LPNs and therapists to patients’ homes, helping patients recover from illness, injury or surgery, avoid unnecessary hospitalizations and manage long term conditions. By creating specialized home health empowerment programs to help patients manage specific chronic conditions, we’re able to further support patient education and help reduce unnecessary hospital visits.
In the home, our team of caregivers gains a deeper understanding of each patient’s unique circumstances, helping them maintain independence longer and increase their overall safety.
Palliative Care in the Continuum of Care
Amedisys’ palliative care in the home offers an additional layer of support to those living with serious illness. Patients can receive palliative care beginning at the time of diagnosis, which provides them with care navigation that helps connect their many providers to their personal goals and preferences for care. By bringing this care directly to patients in their homes, it eliminates the barrier of transportation that often stops older adults from consistently following up on their care.
Advance care planning in palliative care helps ensure that patients are prepared for disease progression and life transitions, recording their plan of care so that all providers stay on the same page even when needs change suddenly or health outcomes are uncertain.
This care can be offered alongside home health when appropriate. A patient living with congestive heart failure, for example, may receive services through home health while also participating in palliative care to help them manage their overall plan of care between multiple providers and ensure quality of life. Like home health, palliative care at home reduces the need for patients to transfer between care settings, which can be overwhelming and stressful and contribute to fragmented care.
Hospice Care in the Continuum of Care
Hospice care represents a natural progression of the care continuum for patients receiving home health and/or palliative care at home. As chronic renal disease progresses to end-stage renal disease and goals of care change to supporting the end of a life-limiting illness, hospice is part of a seamless transition from home health to palliative care and finally the end of life, all in the most comfortable and familiar setting for patients — the home.
Although patients certified by their physician as having six months or less to live qualify for hospice, the average length of stay is 18 days or less for 50% of those receiving hospice. Patients who have been well-informed by the education and support offered by home health and palliative care often choose hospice earlier and experience higher quality of life.
Benefits of the Home Continuum of Care to Providers
There are many advantages for providers whose patients have access to the continuum of care at home. These include:
- Better reputation — The inherent comfort and patient-first nature of care in the home leads to positive experiences and higher patient satisfaction.
- Improved morale — When patients achieve positive health outcomes, providers enjoy a more fulfilling experience and greater job satisfaction.
- Improved value-based outcomes — Higher quality care at home, reduced healthcare fragmentation, decreased hospital readmissions and better continuity of care are the foundation of value-based care models and increased reimbursement.
By providing a continuum of care at home, we offer consistent and coordinated health care and offer many benefits for both patients and providers. Interested in learning more about the difference Amedisys can make for your patients? Contact us today and ask about referring your eligible patients to home health, palliative care or hospice.
Lori Bryan, RN, is Vice President of Growth Solutions for Amedisys. She brings a wealth of home health and hospice experience as an RN Case Manager and several executive positions in post-acute care organizations.
