Easier Chronic Disease Management

For Primary Care Practitioners:

Many practice guidelines for the management of chronic diseases are inconsistent with the time demands of a standard primary care practice. In a study published in the Annals of Family Medicine (Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 3(3): 209-214.), Ostbye and colleagues calculated that managing just 10 of the top chronic diseases according to practice guidelines for a standard patient panel of 2,500 would require 10.6 hours of clinician time per day. This does not take into account any of the other chronic diseases this patient panel would have, preventive care, or acute care.

Of course, it is not a doctor’s job to do everything – only to make sure everything is done. Many physicians have discovered that the home health services of Aspen Healthcare can facilitate chronic disease management for an important subset of patients. As a Medicare certified home health provider, our patient education delivery model involves multiple visits for education of patients, education of caregivers, verification of successful adherence, and monitoring for results. If you know who among your patients meets homebound criteria, you know which patients you can refer to Aspen Healthcare for a comprehensive chronic disease management program. From a practice management perspective, these elements of Aspen’s chronic disease management services will merit consideration:

  • Chronic disease education referrals are usually straightforward cases requiring only initial certification paperwork from a physician.
  • Physicians can bill Medicare for the certification of the home health plan of care.
  • Medicare pays 100% of allowable home health charges from Aspen, so patients incur no additional costs related to the home-based follow-up.

A primary care practitioner’s goals for referring chronic disease management to home health would include:

  • To improve the patient experience and enhance the patient’s self-management skills by expanding the primary care encounter to include home-based follow-up and coaching
  • To enhance the work flow of primary care practitioners by offloading tasks that can be completed by nurses and therapists who are not a cost center to the practice
  • To reduce national healthcare spending by reducing unnecessary declines and complications through enhanced management of high-risk and high utilizing patients.

When you have patients who do not restate their instructions correctly, who demonstrate non-adherence to the management plan, or who are not accomplishing disease management goals, a referral to Aspen Healthcare for follow-up chronic disease management may be indicated. In addition to homebound criteria, Medicare requires a new skilled need. Health regimen teaching typically meets the skilled need requirement, but for it to be a new skilled need, you would look for a situation such as the following:

  • Recently documented worsening of measures (e.g. high glucose, high blood pressure, greater dyspnea, reduced function)
  • Recently documented non-adherence to the health care regimen
  • A documented likelihood of exacerbation in the next three weeks
  • New medications
  • New diagnosis
  • Recent exacerbation
  • New health care regimen instructions such as diet changes.

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