Let the Data Do the Work: Bridging the Home Health to Hospice Continuum
By Amanda Fabozzi, PT, DPT; Director of Clinical Transformation, Medalogix
During those critical days and weeks preceding end of life, patients and caregivers rely on healthcare providers to determine the right type and quantity of care. Phrases like “just right care plan” and “right care, right time” are commonly shared across the industry, but is that all buzz? How do clinicians really know what is right? Can the experience, education and instinct of clinical care teams be enough to shape care plans and guide patients to the best possible outcomes?
Clinical experience, education and instinct are certainly important—but at best, care planning without data intelligence is still based in subjectivity. No clinician can say with any degree of certainty that a home health patient has a 90 percent chance of dying in the next 90 days; or that a hospice patient is 97 percent likely to die within the next seven to 12 days—clinicians don’t have that type of power, at least not on their own.
Let the Data Do the Work: Bridging the Home Health to Hospice Continuum
When a clinician conducts an assessment of a typical home health patient, it starts with the comprehensive assessment. OASIS, coupled with hundreds of other data points, describe describe the physical, emotional, and social condition of the patient. This provides the foundational baseline for the subsequent 60-day plan of care. The OASIS is a powerful tool, but it’s also home to many disparate data points with likely minimal automated insights within the EMR. So how do providers consider acuity and risk when building care plans for individual patients? Most providers have the desire, but the delivery is difficult without the organized insights.
Understanding a patient’s risk for mortality isn’t a subjective formula. The truth around a patient’s risk for decline lies within historical data & outcomes. Predictive analytics organizes that data & puts it to work, equipping clinicians to deliver individualized care to home health & hospice patients at precisely the right time. Sound like forward thinking? Well, it’s possible, and it’s the right thing to do.
According to the Stanford School of Medicine, 24 percent of Americans put their end-of-life care wishes in writing; 16 percent have thought about end-of-life care but have not told anyone about their wishes; and 19 percent have not thought about end-of-life care at all. Further, according to Standford, 80 percent of Americans would prefer to die at home, but only 20 percent actually do. That’s a hard statistic to swallow—together, we can do better. But how do we get there? (Standford School of Medicine, 2021).
Predictive Analytics at Work: Timely Conversations for Proactive End-of-Life Care Planning
Medalogix Bridge, a data science solution that detects the most vulnerable and frail among your population, provides access to data-driven insights to help drive the appropriate type of care to high-risk patients. For patients receiving home health care, Medalogix Bridge provides a risk stratification for likelihood to pass away in the following 90 days. This insight provides a “call to action” to home health practitioners to initiate an end-of-life planning conversation with the patient and family.
Medalogix Bridge clients utilize the tool to prompt earlier care coordination with emphasis on education around the hospice benefit and facilitates conversations around patient-centered goals. There are generally wide knowledge gaps surrounding the scope of hospice care, and many patients are open to the benefit once receiving education. In fact, providers have seen an average of 180 percent increase in billable hospice days by leveraging Medalogix Bridge for advanced care planning conversations. By actively engaging the patient and both services lines in timely, collaborative care planning, providers ensure that each patient’s end-of-life needs and wishes are met, truly informing and supporting the “right care, right time” edict.
What Happens Next? Maximizing the Hospice Benefit with More Data
One of the most significant challenges with planning and delivering end-of-life care under the hospice benefit, is that the dying trajectory is not always linear, making it difficult for clinicians to predict the necessary type and amount of care as the end approaches. Once again, “the right care, right time” challenge ensues, this time with the clinician’s experience, education and instinct informing how and when to adjust in-home services to align perfectly with a patient’s final days. But data shows us that hospices often fall short—there is really no way for clinicians to accurately predict the final seven days of life so that additional RN and social work visits can be planned. At least not on their own.
According to a recent JAMA study, 12.3 percent of patients on routine hospice care in the home did not receive a single skilled visit in the last two days of life (Christian, Plotzke, Teno, 2016). Even more disheartening, patients who died on a Sunday were more than three times less likely to have a skilled visit than those who died on a Tuesday. Every patient deserves to receive the care and comfort they need in their final days. No patient should transition alone— the industry must do better.
Predictive Analytics at Work: Identify Timely Hospice Patient Transitions
All hospice patients deserve to transition with unparalleled dignity and quality. Medalogix Muse is a machine learning solution that identifies which hospice patients are most likely to transition within a week. Muse looks at more than 800 hundred hospice patient assessment data points, including HOS items, vital signs, and other physical and social assessment items, and uses machine learning to predict, with a 97 percent average accuracy, those patients who will pass away in the subsequent 7 to 12 days. With that insight, hospice agencies can plan the right services and intensity of visits to adequately care for the patient and family in the final days of life. Patients at lower risk may require less frequent visits due to their lower acuity level. In both scenarios, the power of the data prompts the agency to uphold “right care, right time” in a patient’s final days.
The Combined Effect? More Efficient and Effective Care
Medalogix Bridge and Medalogix Muse are powerful tools that independently, have transformed clinical practice and patient and financial outcomes for home health and hospice providers alike. Used in tandem, the Medalogix Bridge and Medalogix Muse solutions have the unique ability to change the end-of-life experience for patients, families, and providers across the in-home care continuum.
Home health and hospice clinicians provide exemplary care every day. But the naked eye can’t see everything, especially not the subtle changes in a patient’s status that serve as the very earliest signs of decline. Data-driven solutions can guide clinical decisions, ultimately lowering cost of care while providing support to the patient when it matters most. Whether it be the signs of a disease trajectory indicative of the need for an advanced care planning conversation, or the signs of imminent death, the application is the same: data is able to change the course of treatment so that every patient receives the right care at precisely the right time.
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Christian, Thomas; Plotzke, Mike; Teno, Joan M. (2016, March). Examining Variation in Hospice Visits by Professional Staff in the Last 2 Days of Life. JAMA Internal Medicine; JAMA Network. https://jamanetwork.com/journals/jamainternalmedicine/ fullarticle/2488922 (2021). Where do Americans die? Stanford School of Medicine; Palliative Care.