Wednesday, April 9, 2014

Wisconsin's PATH ALONG Data matches National Values

PATH ALONG staff reviewers proclaim the microcosm (PATH ALONG) data matches the macrocosm (Centers for Medicare and Medicaid) hospital readmission values.  The Centers for Medicare and Medicaid  (CMS) reports one in four patients being served in a skilled nursing facility are readmitted to the hospital within 30 days. 

The Wisconsin PATH ALONG model data indicates individuals being transitioned from a nursing home to the community carry a huge risk for hospital readmission.  A structured data review by PATH ALONG researchers indicate 22 percent of individuals being transferred from a nursing home to the community resulted in a hospital readmission.

This is significant when one considers Wisconsin State Programs like  Family Care, Wisconsin Partnership, and I Respect I Self Direct ,  are specifically designed health  initiatives  to support individuals in their own homes.  The Centers for Medicare and Medicaid (CMS) report two thirds of individuals being served by a nursing home are enrolled in Medicaid.

Simply stated, individuals being transitioned from a nursing home to the community carry a huge risk of hospital readmission.  The elevated risk does not disappear with nursing home discharge, but actually follows the patient into the community dwelling.   Structuring supportive home care to improve health outcomes for an individual transitioning from a nursing home to the community requires advanced care planning.  PATH  ALONG staff recognize the need to insert strategies implemented to improve the process for addressing acute changes of condition.

PATH ALONG model staff have adapted the following initiatives in to their practice.
  • define path acute condition changes are treated
  • define primary care rapid path 
  • define communication path per discipline
  • define care transitions path
  • define SNF path for performing ADL's
  • define navigation path between multiple pay sources
  • define additional resources secondary to acute changes in condition
  • define path for sharing information
An individual leaving a nursing home for a community dwelling can expect the high risk for a hospital readmission to follow them.  Expect acute conditions presenting in the community dwelling to require additional resources.  Expect the individual to require rapid access to advanced primary care.   Indviduals expecting to transition from a nursing home to the community will need more from all involved.

Home Care Path celebrates 4 years of successfully serving seniors in South Central Wisconsin

 
 

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 Home Care Path  www.homecarepath.com and the Wisconsin PATH ALONG model deliver an advanced supportive care service.  Helping seniors in the home, with clinic visits, at the hospital, nursing home and assisted living facility.  Helping seniors downsize with a move in to an adult child's home. 2014 rates are 20.00 per hour.  Simply call 608-432-4286 to schedule an interview.  We can be there when you are working.  We accept long term care insurance.  Services can be tax deductible.  Help with resources and the transition from private payment to public funded programming.  Valuing home and human life
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