Changes are coming and some are already here as part of ACA. It has been proven that getting healthy at home, often referred to as 'medical home', is going to be critical to reducing cost of care and in technical jargon reducing the Medicare Spending Per Beneficiary (MSPB). This is not only a cost reduction opportunity this is an ethics opportunity and human opportunity. Being in a hospital, a skilled nursing facility (SNF) or long-term acute care facility (LTAC) is emotionally exhausting for patients and their family. We all know that a person is body, but mind and spirit are as essential in health and recovery.
We can all intuitively agree, if you could ask my grandma Stella who had a history of escaping health facilities as she walked out the front lobbies in her hospital gown with her dupa showing (polish for butt), that getting a person home as soon as possible makes sense. But (the non-dupa kind) we can't just send a person home to heal, recover and without the skills, knowledge and confidence to integrate prescriptions (medicines, diet, exercise, self monitoring, etc.) into their daily routine. Home health nurses, therapists, caregivers and spouses can play a critical role in coaching and educating patients in their home but it starts in the hospital. Med reviews, identifying personal goals, emotional assessment, a list of skills a patient should acquire, an understanding of their transition home, etc. all need to be part of the plan. These are unique for each person and take time. We can invest dollars to implement home monitoring systems that run out after a set time and do not build sustainable change or we can invest human time understanding the person and coaching/teaching the skills needed and integrating the right tools for the right situation so a patients confidence and knowledge is built and they can successfully get well at home.
Getting or staying healthy at home is the best choice (financially, ethically, emotionally, psychologically) and we are creating the steps to achieve successful healing at home. Join us on the journey to living healthy at home. Please share your perspective and ideas as we finish developing our system of getting and staying well at home. This system is develop for the person and with the support of caregivers, spouses, families, nurses, therapists, social workers and pharmacists.