Receiving personal care in the privacy and comfort of home can be important for recuperating, chronically or terminally ill patients or persons with disabilities. In-home care facilitates independence and functional improvement. Home health patients receive medical, nursing, and/or therapeutic treatment through a wide range of health and social services. Receiving home health care reduces unavoidable readmissions, and studies have shown that patients recovering from injury, sickness, or surgical procedures heal more quickly and with fewer complications when recovering at home versus in a medical facility.
Moving a patient from a hospital to their home or care facility in a community setting is a delicate process. Patients, family members or caregivers can receive confusing recommendations, a laundry list of medications, and conflicting instructions regarding follow-up care. If they are not included in planning or provided with clear “next steps” there can be significant gaps in post-discharge care. As a result, patients will most likely return to the hospital, and often times with more complications than before.
Social conditions and chronic disease are related. Overcoming social factors can be a challenge for the two-thirds of Medicare beneficiaries with two or more chronic conditions. Many of these patients struggle with housing concerns, lack of access to transportation, inadequate nutrition, and job loss. Some are isolated from family and face fragmented care.
It’s important to remember that patients with chronic conditions can still enjoy life. While chronic diseases can affect a patient’s ability to perform some important daily activities, this doesn’t have to completely restrict social engagement and their enjoyment of family and friends. Enhanced and ongoing communication with doctors, a focus on medication compliance, and patient health education offered by chronic care management (CCM) can provide immediate and long-term benefits. CCM and Transitional Care Management (TCM) can help doctors improve patient health-related quality of life, and boost the number of healthy physical and mental days.