Monthly Archives: December 2013

Care Transitions by Pyramid Home Health Services

Pyramid Home Health Services assists many Missourians recently discharged from an in-patient hospital stay to rehabilitate at home through the services of its home health division. These services provide individuals with the skilled nursing, therapy, social service and dietary assistance required to recover in the comfort of their own home. Beginning in 2014, Pyramid Home Health Services will begin providing comprehensive care transitions management under contract to health plans and hospitals operating in Missouri.
Many individuals are discharged to home without a specific need for traditional home health services but who are still at risk for complications that may lead to unnecessary ER usage or a re-hospitalization within 30-days of discharge. The key to avoiding this undesirable outcome lays in successfully managing those patients transition from the in-patient setting to the community. Pyramid Home Health Services Care Transitions is a 30-day program specifically developed to avoid ER usage and hospital readmission during that period. Specifically the program:
1- Makes in-person/ in-facility contact with patients at high risk for re-hospitalization prior to their discharge from the hospital. Pyramid Home Health Services staff develops a rapport with the patient and ensures they are knowledgeable of their condition, medical record, medications and, generally, their own responsibilities relating to a successful recuperation at home prior to their leaving the hospital. All patients receive a “Transitions Packet” containing vital information regarding their condition, warning signs and symptoms, discharge medications and instructions, the contact number for Pyramid Home Health Services’ 24×7 nurse line, their physician(s) contact information and follow-up visit dates, and list of the addresses and hours of operation of emergent care clinics nearest their home.
2- Conducts pre-discharge assessment of the safety and accessibility of the patient’s home and provides a written report to the patient’s following physician(s), the discharging hospital, and their health plan covering any identified safety hazards, barriers to self- care or family assisted care, and required home modifications or DME that may be necessary for a successful transition to home. Additionally, if necessary, Pyramid Home Health Services will coordinate orders and referrals for ancillary services, supplies and pharmacy and ensure any required services, supplies or medications are in the patient’s home upon their return.
3- Delivers a home visit within 48- hours of discharge, or sooner where required, to evaluate the return to the home process, the patients satisfaction with the same, address health questions and concerns, check vitals, and review medications and the patient’s knowledge thereof regarding regimen/ dosage(s)/ side effects. Where beneficial Pyramid Home Health Services provides tele-health based MTM (Medication Therapy Management) with a MTM certified pharmacist. Additionally, Pyramid Home Health Services staff reviews and updates the transitions packet, schedules necessary follow-up physician visits and/or ancillary care provider visits, arranges necessary transportation thereto and again reviews with the patient relevant condition warning signs/ symptoms. A written report of this visit is provided to the patient’s following physician(s), the discharging hospital and the patient’s health plan.
4- Within 48-hours of the initial home visit and no less than weekly thereafter Pyramid Home Health Services conducts check-up calls with the patient at pre-arranged times to review their stability at home and their satisfaction with the home transition process. Included in these calls is reminder of and verification of the patient’s making their required physician appointments. If necessary, Pyramid Home Health Services will conduct additional home visits should its calls to the patient or in-bound calls from the patient indicate a potentially worsening condition. Written report of these calls/ visits will be made available to the patient’s following physician(s), discharging hospital and health plan.
If you are a Missouri Hospital or Health Plan and would like to discuss contracting with Pyramid Home Health Services to manage the Care Transitions process for your patients and beneficiaries visit us at www.pyramidhhs.com or call us at 888-880-6565.

Practice Extender

Practice Extender:
Pyramid Home Health Services assists many Missourians to manage the challenges of living with multiple chronic conditions at home. Beginning in 2014, through its new Practice Extender Program, Pyramid Home Health Services will offer these Patient’s Physicians a powerful tool to better coordinate their care and live healthier.
Practice Extender Services Includes:
1- 24X7 Nurse Line: The availability of a Pyramid Home Health Services Clinician 24/7 to provide telephone based response to patient health questions and concerns and to triage alternative care options to the ER after hours. Response is stepwise and ranges from the least invasive, advice, follow-up telephone monitoring and scheduling of a physician office visit to referral and arranging of transportation, if required, to the nearest open emergent care clinic to dispatch of an RN or NP to the patient’s home to evaluate symptoms and take appropriate action. All documentation of interactions will be provided to the patient’s Physician within 24- hours or sooner where appropriate.

2- Tele-Health: Pyramid Home Health Services Tele-health platform allows Physicians to “cast” HIPPA compliant and billable Patient office visits from the Physician’s practice location into their Patient’s homes when Patients are unable or unwilling to travel to the practice location. Pyramid Home Health Services will assist the practice to preschedule these visits and deploy the appropriate staff and equipment to the patient’s home to ensure a thorough examination, including review of vitals and, where necessary, collection of lab specimens.

3- Intermittent NP staffing: Staffing can be for “In-Office” needs, including managing Tele-Health Services, or for conducting home visits. This service includes provision of all requisite contracting between the NP and the Physician, scheduling, and electronic documentation of patient services.

4- Medication Management: Includes Tele-Health based MTM with a certified Pharmacist, in-home nurse review of and teaching on medications and medication compliance, electronic medication reminder calls with tracking and follow-up, free home delivery of multi-dose packaged medications, specialty drug compounding and administration.
Pyramid Home Health Services provides Physicians a range of partnering options. Where services are individually billable to a patient’s insurance, the Practice or Pyramid Home Health Services may bill for the same with Pyramid Home Health Services receiving payment on a fee for service basis directly from the insurance company or under contract to the physician. Where practices are managing the care of Patients under capitated agreements or are participating in “Gain Share” or other “Shared Savings” programs, Pyramid Home Health Services will contract on a per member, per month basis (PMPM) with the practice or the intermediary.
Practice Extender from Pyramid Home Health Services will permit Primary Care Physicians to qualify for the Chronic Disease Management Fees established in the final 2014 Physician Fee Schedule.
If you are a Missouri Physician and would like to add Practice Extender as a benefit for your patents, please contact Pyramid Home Health Services on line at www.pyramidhhs.com or call us at 888-880-6565.

Delivering the Right Care at the Right Time

The Institute of Medicine defines appropriate and affordable care as “Delivering the right care at the right time with the right provider in the right setting.” Technology enabled home health providers like Pyramid Home Health Services in partnership with Patient’s Physicians represent a uniquely well suited team to ensure delivery of the type of maximally coordinated and effective care contemplated in this definition. Within the operational perimeters of Affordable Care Act (ACA), these partnerships provide a distinct advantage for both Physician and Home Health company and, more importantly, for patients.

Nearly a quarter of Medicare beneficiaries have five or more chronic conditions. These individuals account for approximately two thirds of total Medicare Spending. As we’ve discussed in earlier blog posts, the care provided for these individuals, especially where they are dual eligible, is largely uncoordinated and disjointed. This is one reason why this population of patients is fully 100-times more likely to experience a preventable hospitalization than non- chronically ill Medicare beneficiaries. Under the ACA, failure to better coordinate and manage these patients’ care has a huge price tag for providers; particularly hospitals, in the form of readmission penalties and forgone revenue from “Shared Savings” opportunities. Additionally, failure to deliver quality outcomes can imperil long standing referral relationships as “At Risk” providers can ill afford to be further imperiled by low performing partners. Through the application of these economic consequences, the ACA is very definitely driving a strong shift up and down the continuum of care toward delivering desired outcomes at lower cost.

Embedded in the ACA are multiple opportunities for Physicians and Home Health Companies to work together to deliver better outcomes for chronically ill patients. One of the first areas evidencing this opportunity can be found in numerous Independence at Home Demonstration (IAH) programs. Basically IAH are Physician, Nurse Practitioner or Physician Assistant led house call programs. Under IAH guidelines providers are paid for their services but they have the opportunity to share in 80% of Medicare’s savings after meeting a minimum 5% total savings of the fee for service average for beneficiaries in their practice region. While the IAH demonstration specifically is only permitted to enroll up to 10,000 Medicare beneficiaries nationwide; its pay for performance metrics are embodied in numerous other ACA initiatives.

Where Medicaid is concerned, the ACA establishes the opportunity for State Medicaid plans to create Health Homes. Eligible beneficiaries are those who qualify for medical assistance under a state plan or waiver and who have two or more chronic conditions or who have a chronic illness and a concomitant mental health condition. We in Missouri were the first in the nation to establish health home programs and today they are operating within FQHC and CMHC state-wide. These initiatives couple per member per month payment for care coordination with the opportunity for states and providers to share in the Medicare savings resulting from better coordinated care.

The ACA additionally funds a vastly expanded national preventive health initiative. Annual physical examinations, health risk assessments, and personalized disease prevention services are all mandated to be fully covered for all Medicare beneficiaries.

In the healthcare landscape molded by the ACA, Pyramid Home Health Services represents a perfect practice extender for Missouri Primary Care Physicians. With new patients resulting from expanded insurance coverage generally as well as the aging of the baby boomer population, it’s going to be tough for Primary Care Physicians to meet the increased demands on their time. Through the use of Pyramid Home Health Services’ Nurse Practitioners, RN, and HIPPA compliant Tele-Health portals, these practitioners are enabled to see patients at home without incurring the expense and inefficiency of personally travelling from house to house. When cast from their offices these interactions are billable per the standard 2014 Physician Fee Schedule; so with Pyramid Home Health Services, Physicians can focus on those patients who are most critically in need of their personal, physical presence while also meeting the demands of their growing patient base by treating many of those patients in the comfort of their own home.

Where Physicians are participating in population health management strategies like IAH, Health Homes and under risk based contracts with managed care entities, utilizing Pyramid Home Health Services staff and its various monitoring technologies provides a powerful tool to identify issues prior to their becoming ER visits and hospitalizations. Where these relationships are concerned, Pyramid Home Health Services can work with these providers on a shared risk or per member, per month basis. Including in these arrangements are various levels of home monitoring, laboratory, referral to ancillary services and our MTM certified Pharmacists.

An effective partnership with Pyramid Home Health Services offers Missouri Physicians the opportunity to further their patient relationships by making themselves and their practices more available to all patients all the time; which is exactly in-line with the policy push implicit in the ACA, “To deliver the right care at the right time with the right provider in the right setting.”

If you are a Physician in Missouri and would like to talk further about how we can help you extend your practice into your patient’s home, visit Pyramid Home Health Services online at www.pyramidhhs.com or call us at 888-880-6565.