Home Health & Hospice

Insider’s scoop | Disease management

Homecare Insider, May 9, 2016

Editor’s note: This week’s Insider’s scoop is from An Interdisciplinary Approach to Homecare. Medicare is not concerned with outcomes specific to therapy, nursing, or social work; payments are based on the overall patient outcome. Agencies need to develop a collaborative, interdisciplinary approach to patient care, and this book can help them get started or fine-tune their teams. Click here for more information.

The grouping of patients is by their chronic “condition” or diagnosis, such as ischemic heart disease, diabetes, chronic obstructive pulmonary disease, asthma, and heart failure. One challenge is that patients frequently have more than one diagnosis at any given time, and this may put them in more than one group.

This concept has been mirrored in homecare, when agencies have utilized disease-specific pathways and have struggled with co-pathways for additional conditions. Setting priorities and sequencing issues can be quite difficult with the medically complex population being served in such settings. Services other than nursing are not planning care from the diagnosis viewpoint; rather, they plan from the viewpoint of the impact the diagnosis or diagnoses have had on the patient’s quality of life. This can further complicate implementation of disease management models in the homecare setting. This does not negate their value in any way but requires additional discussion to determine what components fit best in this specific practice area.

As opposed to planning care based on a single element such as the diagnosis or assuming that there is only one discipline coordinating the necessary services, care management looks at patient issue-specific driven models.