At Encompass Health – Home Health & Hospice, we believe in providing the right care, at the right time. Using predictive analytics, our Care Management Division (CMD) is able to identify and monitor high-risk patients to supplement our home health services between visits.

The CMD is a clinical-based call center, comprised of former home health clinicians, that gives high-risk patients 24/7 access to skilled clinical staff.  

“The goal of this division is to achieve the Medicare triple aim: enhance patient quality and improve satisfaction while reducing the overall cost of care,” said Pam Morris, director of care management at Encompass Health – Home Health & Hospice.

How it works

Upon admission to home health services, an Encompass Health clinician performs an OASIS assessment on each patient. The CMD then utilizes Medalogix Touch, a risk stratification software that analyzes factors such as fall risk, risk of hospitalization and functional scores, to identify high-risk patients.

Medalogix is a leader in predictive analytics and data science for home health and hospice services, in which Encompass Health made a minority equity investment in earlier this year.

Once high-risk patients are identified, the CMD uses clinical outreach and automated calls to provide additional support to these patients. These calls enable the CMD to monitor the patient’s status and symptoms and provide patient education.  

Teachable moments

Patient engagement is key, which is why active listening, motivational interviewing and the teachback method are evidence-based practices that the CMD uses to make the most of every telephonic encounter.  

The CMD recently performed a routine call to a cardiac patient, when the patient’s daughter answered. His daughters were new caregivers and didn’t know much about his disease or what to monitor for. The CMD was able to instruct the patient’s daughter on the signs and symptoms of a heart attack, and what to do if they noticed them, as well as when to call CMD versus 911.  

That same week, the daughters called the CMD back as their dad had experienced some of the symptoms they had been told to watch for. After evaluating his symptoms, they decided he needed to go to the emergency room, where they determined that the patient was actively having a heart attack.

His daughters’ quick recognition of his symptoms provided him the emergent care that he needed. The patient was able to receive the right care at the right time, which resulted in the best possible outcome. The patient’s daughters called the CMD to thank the nurse for the recent teaching, as their dad might not be here today if they didn’t know the signs to monitor.  

“Our surveys have shown that patients who received CMD services had a higher patient satisfaction score on the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey, compared to those who didn’t receive them,” said Morris.

Closing the gap

The CMD uses the Medalogix Nurture program as well to target patients who have recently discharged from our home health services. The CMD performs patient satisfaction calls at different milestones to monitor for changes or decline in condition, falls and hospitalizations that may warrant a need for additional home health services.

In light of the Patient Driven Groupings Model (PDGM) that takes effect on Jan. 1, 2020, Encompass Health is applying an even greater focus on the CMD to right size the home health plan of care.

“This model we created works well for us as well as our ACO partners,” said Luke James, chief strategy officer at Encompass Health – Home Health & Hospice. “We’re willing to invest in our Care Management Division to service their high-risk patients, free of charge to our partners. Much like the physicians in these ACOs, we don’t get any return on investment unless high-quality care is delivered, and financial savings are produced.”

“Our services result in increased touchpoints for patients, which improves patient satisfaction, and ultimately help us close any gaps in their care,” Morris said.

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