Transitions from hospital to home remain one of the biggest problem areas for the U.S. health care system.
There are benefits of a patient staying in the hospital. Chief among them is the ability to have regular attention being paid to the patient.
Home-based care enablers are targeting that precious transition period to ensure that patients don’t feel the loss of the hospital post discharge.
“Patients who are in the hospital are seen multiple times a day by a nurse, a physical therapist, a doctor,” myLaurel President and Chief Medical Officer Dr. Marcy Carty told Home Health Care News. “Then they’re discharged, get in a car and don’t see another health care provider for two weeks. That slow ramp to home has really been an effective way for us to have an impact on patients.”
The New York-based myLaurel provides acute care in the home for people who are frail, elderly or complex. To do that, it partners with payers, health systems and home health providers through value-based payment arrangements.
Its offerings include Rapid Advanced Care and Recovery at Home, two intervention programs for patients pre-hospital and post-discharge that aim to lower hospitalization visits and readmission rates for health systems and its home health provider partners.
This year, myLaurel launched Acute Care at Home, a second post-discharge initiative that aims to facilitate the transition of care from the hospital to the home.
“We partner with hospitals to either take someone who wouldn’t be otherwise admitted, take them directly home out of the emergency room and continue that acute care in the home,” Carty said. “Or we can take someone home who has stabilized so that we can transition them home and allow them to both continue what they were getting in the hospital while also making sure their services are coordinated and that their caregivers feel empowered to continue that care.”
The need for this kind of service really started to emerge post-pandemic. Overcrowding in hospitals and emergency rooms have forced companies like myLaurel to innovate and to fill a need in the marketplace.
The second component of this, Carty explained, is how the industry has shifted to value.
“A lot of hospitals are also now part of a system that takes risk for patients,” Carty said. “They’re taking value-based contracts from payers and they want to do what they can to avoid admissions and so that’s like a perfect target for us. Both use cases allow us to leverage our team in ways that we want to.”
Before her time at myLaurel, Carty worked for Blue Cross Blue Shield where she said a third of patients saw a primary care doctor within two weeks post-discharge.
That quick turnaround meant that the ramp from hospital to home included significant barriers for patients adapting to their new situation.
“What we found is being able to take someone out a couple of days early, continue that care in the home and then continue to offer touch points for two weeks is a much better patient experience,” Carty said. “It also decreases your risk of hospital acquired infections, decreases your debility and a bunch of other things that lead people onto SNF.”
It also allows the caregiver at home to learn more slowly, Carty said.
For home health providers taking on risk, myLaurel can also act as a complementary piece in the mission to drive down readmission rates.
“Many home health companies are also starting to take risk for readmissions,” Carty said. “Readmission reduction is not only about taking care of the physical ailments, right? Sometimes those symptoms worsen. Our services really are complementary. Instead of calling 9-1-1, we can be called to keep that patient at home. Home health providers, as they take risk for readmissions, we’re an incredibly important tool to keep people out of the emergency room.”
Carty also pointed to her clinical staff’s experience with chronic conditions and complex patients as an added benefit to home health agencies needing another card to play.
“Your 83-year-old with six chronic conditions comes into the ED,” Carty explained. “It’s not the ED visit that all of us are worried about from an MA plan and total cost of care perspective — it’s the admission and then the subsequent SNF costs. We’re a really good tool in the tool belt to work with home health just because of the acuity we work with and what we can bring into the home.”
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