Patients Need More Options After Hospitalization: Case Study

Home healthcare provides in-home clinically advanced services to patients following a hospitalization or physician visit. However, many Medicare patients, upon discharge from a serious hospitalization, have health needs that prompt discharge planners to recommend post-acute care in a Skilled Nursing Facility.

In the case study below, we can see how the proposed Choose Home program would provide an additional option of clinically advanced care in the home, with extended care services as a supplement to the existing Medicare Home Health benefit that would enable more Medicare beneficiaries to receive post-acute care in the home following a hospitalization.

An 81-year-old patient presented to the emergency room with their caregiver for Altered Mental Status. The patient had mild baseline dementia but was still able to reside in their home and manage care with the assistance of their caregiver who lives nearby. Upon admission to the hospital, the patient was alert and oriented, but was showing aggressive behaviors toward the caregiver, as well as the clinical staff. After an assessment from the physician and testing, the patient was diagnosed with a urinary tract infection and was placed under observation status on the unit. 

Prior to hospital admission, this patient was ambulating independently without an assistive device, bathed, and dressed independently, and was able to manage their medications from a medication planner filled by their caregiver. The caregiver was coming to the patient’s home every day for approximately 2-3 hours to assist with meal prep, light housekeeping, and laundry. According to the caregiver, the patient was typically safe at home alone, but they had concerns about them returning home without assistance due to their current mental status.

The family was interested in skilled home care services but did not feel that the frequency of services was sufficient to provide the current level of care needed. Private non-skilled services were also offered; however, the family was unable to afford the additional cost. Physical therapists worked with the patient and recommended a transfer home based on the patient’s functional ability, however the family continued to express concerns regarding the patient’s ability to return home safely due to their current mental status. The family was also concerned about sending the patient to a Skilled Nursing Facility for short term rehabilitation, as they were concerned this may also exacerbate the patient’s dementia.

The family and caregiver ultimately chose for the patient to discharge to a short-term Skilled Nursing Facility as they felt they did not have sufficient clinical care and supports in the home setting for the patient to return home at discharge.

There is a better way to care for seriously ill Medicare beneficiaries after hospital discharge. The proposed Choose Home program, a cost-effective and patient preferred home-based extended care program to provide additional care services, would supplement the existing Medicare Home Health benefit and better support patients who choose to recover at home following a hospitalization.

For this patient, Choose Home could have provided a 30-day extended care benefit that would provide additional skilled nursing care and up to 360 hours of personal care while the individual’s mental status returned to baseline. Furthermore, this new program could assist with remote patient monitoring and provide caregiver support that would allow the family to feel more comfortable with this transition.

Bipartisan, bicameral legislation – the Choose Home Care Act (S. 2562/H.R. 5514) – has been introduced in Congress to establish this new Medicare program.

As support continues to grow for this legislation, it is critical that lawmakers hear from members of the home health community about its importance. You can help by urging your lawmakers to support the Choose Home Care Act and submitting a letter to your local newspaper to raise awareness!