Nearly two years ago, Help at Home launched its care coordination program, with the belief that caregivers remained an untapped resource for valuable business insights.
Broadly, the company captures detailed observations from caregivers in real time to identify client needs and predict unforeseen events.
The care coordination program depends on caregivers submitting weekly observations and reporting any changes in client conditions.
Community health workers (CHWs) also conduct a self-reported health assessment using the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities Health-Related Social Needs screening tool. This tool includes 24 questions about the home environment and access to eligible benefits and services. These questions help identify issues such as housing instability, food insecurity, transportation challenges, financial strain, safety concerns and lifestyle factors that can affect a client’s ability to achieve long-term health goals.
“We’re uniquely positioned, using the millions of hours we spend with our clients, to connect home care to health care through our innovative care coordination management programs and services supported by our value-based care philosophy,” Julie McCarter, president of care coordination at Help at Home, told Home Health Care News. “Through the launch of our health care coordination strategies that build on our longitudinal caregiver-client relationships, we’re addressing access to care, health-related social needs and unmet client health needs, advancing care as we improve quality and cost outcomes.”
The Chicago-based Help at Home is one of the largest home care providers in the country. It provides home- and community-based services (HCBS) via over 200 locations across 11 states.
In its first year, the program made one million observations and carried out 4,000 proactive interventions that had an impact on the health care system. These interventions included scheduling pulmonology appointments when there was a decline in breathing and mobility, activating mental health resources when there were signs of agitation or mood changes and connecting individuals with food resources when food insecurities were identified. The results of these interventions included a 31% decrease in emergency room visits, a 37% decrease in inpatient admissions compared to the previous year, and a 51% improvement in depression, among other positive outcomes, according to McCarter.
“Our caregivers serve as an extra set of eyes and ears in the home, and through the program, they can digitally capture physical, behavioral and environmental observations,” McCarter said. “Clinical teams can assess, act and prevent avoidable health events in real time to avoid unnecessary hospitalization or institutionalization.”
McCarter mentioned that the clinical care team supporting caregivers includes CHWs. These CHWs typically reside within the community they serve and share the same ethnicity, language, socioeconomic status and life experiences as the client population, allowing for the formation of trusting, organic relationships.
“The results of caregiver tools and care teams engaging populations with high-tech, high-touch wraparound clinical efforts are proving to reduce emergency room visits, inpatient utilization, close preventative gaps in care, increase primary care and optimize health care benefits and services,” McCarter explained.
Furthermore, Help at Home reports that caregivers involved in the care coordination program have higher net promoter scores, demonstrating the program’s ability to improve caregiver satisfaction and retention, making them feel valued and motivated.
“Caregiving can be a difficult job, so we are attentive to the caregiver and work to elevate the caregiver role by providing a village of support through care coordination clinical care teams,” McCarter said. “We’ve seen this lead to greater caregiver satisfaction scores and tenure. Not only does the program support client health and wellbeing, but it also focuses on identifying and supporting the caregivers’ needs. Through the program and that understanding, we’ve found that nearly 50% of caregivers expressed that having a better understanding of their clients’ conditions or needs and how they can be a part of the solution helps them to alleviate their worry and stress.”
Building on the strength of the company’s foundation, core service offerings and long-term relationships, McCarter said that the company is expanding its efforts. Caregivers now have a deeper understanding of a client’s overall health journey and how they can improve the quality of life for underserved populations who wish to age in place.
“We’re energized by the program’s results thus far and are continuing our journey to build on learnings and successes,” she said. “As we move to 2025, we’re excited about embarking on a broader clinical care delivery journey that furthers the value we can provide to our partners, clients and caregivers with value-based care and wraparound support programs to drive quality outcomes and total cost of care opportunities – further connecting health care to home care.”
Companies featured in this article:
