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The Challenge Revolving door readmissions are driving up hospital care costs and causing needless harm to patients, especially elderly people with multiple chronic diseases. Infections and other medical conditions acquired as a result of hospitalizations are becoming more prevalent.
Current senior care models are not improving outcomes nor reducing the number of hospitalizations. Senior population overwhelmingly wants to age in place but is very concerned about their ability to do so. 22 million households (nearly 1 out of 4) care for an elderly friend or relative. More time is lost from work due to elder care than child care.
The number of those over the age of 65 is growing dramatically. There are 10,000 new Medicare recipients added each day. In 2000 the number of seniors over the age of 85 was 4.2 million. By 2010 the number is estimated to be 6.1 million. 83% of our Medicare beneficiaries suffer from one or more chronic conditions.
The Mission and OpportunityIt is the mission of Stay Home Senior Services Inc. to provide consulting services to healthcare providers who manage our at-risk senior population. These healthcare providers are in the process of implementing a revolutionary "SENIOR MEDICAL HOME" care model based on a formula which identifies and then leverages existing healthcare delivery organizational infrastructures and partners with technology service providers to empower at-risk seniors the ability to stay healthy at home. This care model will motivate and help seniors remain compliant with their prescribed medical treatment plan. This will improve health outcomes in a major way. In addition, by implementing any of part of this revolutionary care model, care providers and those who pay for senior care will ultimately benefit from a substantial savings in the cost of managing seniors living with chronic conditions. Implementation of this care model will create immediate healthcare delivery improvements for all stakeholders who provide senior healthcare services.
Relevant FactsMany experts are advocating changing the way chronic care is managed in the US and are writing about the advantage of a “Medical Home” care model as a way to cut healthcare spending. The infrastructure of this care model is already in place as shown by the successful pediatric chronic care model. What is missing are remote health condition monitoring services and a healthcare provider (stakeholder) communication plan to facilitate immediate positive changes. By utilizing a proven and unique model of remote health monitoring service, this goal is achievable today. The resulting daily feed back from interactive health condition monitoring will empower and motivate seniors to remain compliant with their prescribed medical treatment plan. Another benefit of proactive remote monitoring of daily health conditions is that the data will facilitate communications between all stakeholders who share in the wellbeing of the senior. At-risk senior population will be able to stay healthy and in their own home. Proactive Health Condition Monitoring will empower at-risk seniors and their care givers to “self manage” chronic conditions through daily coaching and communication. Acute Care admissions decrease Risk of Emergent Care decreases Cost of healthcare expenditures for this population segment will be substantially reduced. The Senior Centered Medical Home care model creates a partnership “team” between the at-risk senior, Primary Care Provider (PCP), Family Care Giver(s), Sub-Specialists, Home Health Agencies (HHA), and “monitored” Remote Monitoring (Telehealth) services providers. The PCP is the coordinator and communication hub for healthcare needs of the at-risk senior/patient. A senior/PCP relationship where the PCP is the first point of contact for healthcare needs and proactive changes in condition minimizes with the goal of eliminating the need for a patient to receive “crisis care”. This new model of care is accomplished in part by implementing and coordinating any of these cost effective programs and technology: 1. Create a relationship with a (cost effective) remote health/compliance monitoring service to automatically alert PCP/family caregiver of any potential changes in condition. 2. Implement/utilize a data exchange/electronic health/medical record for sharing patients health information between all stakeholders 3. Implement a universal communication strategy for facilitating communication between all stakeholders. 4. Work with payers that will reimburse for E-visits, E-Medications, and remote health condition monitoring and will reward for reduced cost of care (risk sharing). 5. Create a network of ancillary care and service providers and invite them to participate in the universal communication program. 6. Provide cost effective point of care documentation devices to ancillary care and service providers that will document service needs and service delivery.
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