1. The Role of Private Duty Home Care in Reducing Hospital Readmissions &
Enhancing Quality Of Life
Taking Private Duty Home Care to a Whole New Level
Hospital Assisted Nurse Discharge Service (HANDS)
and BrightStar Clinical Pathways

2. The Opportunity
• Hospital/Health System
As part of the Patient
Protection & Affordable
data will be scrutinized at a
Care Act (PPACA), there number of levels and
are a number of changes failure to achieve certain
that will impact
reimbursement to national CMS benchmarks
hospitals and other will result in
healthcare systems
– Financial Penalties
• Excessive Readmissions
National efforts are
underway to reduce – Less Robust Rewards
potentially preventable • Poor Customer Satisfaction
hospital readmissions and
optimize the patient • Poor Outcomes of Care
experience

3. *Centers for Medicare & Medicaid
Services, Public Affairs, April 2009
Medicare data shows that nearly 1 in 5
patients who leave the hospital are
readmitted within the next month
and that more than 75% of these
Healthcare readmissions are preventable*
systems need to
look for new
solutions since Research has demonstrated that many
existing of the return trips can be prevented
approaches are with an in-home care program
not solving the that includes proper education and
problem. supervision.

4. Top Reasons for 30-day hospital readmissions:
 Failure to make follow-up appointments
 Lack of communication
 Failure to understand medication management
 Absence of in-home support
 Non-adherence to lifestyle recommendations
 Failure to understand and actively participate in the
management of their chronic disease

5. At BrightStar we utilize a Best
Practice approach to care
following the
National Quality Standards of
The Joint Commission

6. Cutting Edge Clinical Programs
The Framework:
Making More Possible
BrightStar
We are companions on LifeCare
the healthcare journey BrightStar
our clients take. KidCare
Clinical
Pathways℠ Staffing
BrightStar’s clinical
programs allow us to HANDS
partner with the client,
their family and their Person-Centered Care
healthcare team to Clinical Expertise
enhance quality of life National Quality Standards
and improve care
outcomes.

7. BrightStar’s Clinical Pathways ℠ and HANDS
Program was inspired by nationally recognized
care transition programs:
Coleman Care Transition
Intervention Program
which reduced hospital readmissions by
50% at 30, 60 and 90 days

8. HANDS is a transitional care program focused
on a safe transition home
 After leaving the hospital it is important that the patient
have a direct link to an accessible care provider.
 HANDS provides that link, bridging the transition to
home and addressing issues and questions that arise.
 Medicare agencies may not be able to be there within
the 1st - 24 hours and sometimes not for 2-4 days.

9. • BrightStar’s Hospital Accelerated Nurse
Discharge Service (HANDS) is a transitional
care program to facilitate a safe discharge
home.
– It is ideally the beginning of a journey we take
with the client and their healthcare team.
HANDS: • It begins at time of discharge and continues
for a minimum of 24 hours
– critical transition time for
What is it to re-engagement in the home setting.
• A visit by our Registered Nurse Care
Our Manager is the cornerstone of the program
– Assessment, Medication Reconciliation, Disease
Partners? State Education w/attention to Red Flag
Symptoms
• Person-centered services performed by our
CNA
– Transportation from hospital to home, Home
Safety Check, Light Housekeeping, Retrieval of
Simple Supplies (medications, groceries, etc),
Light Meal Prep, Transition Check List which
includes phone calls to loved ones,
arranging/confirming follow-up appointment with
discharging physician

11. • HANDS Basic
– 3 hours CNA time
HANDS Basic
– 1 RN Home Visit w/i 4-8 hours of
Services hospital discharge
• HANDS Plus
– Everything included above
– Pre-discharge RN Visit at hospital
(meet & greet, chart review,
discharge instructions, etc)
– 1 additional RN visit
– 24/7 RN phone call availability for
HANDS Plus 30 days
Services – Detailed medication
instruction/med set-up if indicated

12. BrightStar Clinical Pathways
Empowering individuals with chronic illness
through our best practice approach

13. Simply put…
BrightStar Clinical Pathways ℠ is a
–patient centered
–condition-specific
–transitional care program
Focused on
–reducing negative outcomes
–optimizing quality of life

14. BrightStar Clinical Pathways SM
Patient Centered
Evidence-based
Condition-specific
Best practice approach
Time-limited (4 wks)
RN Clinical Pathway Coordinator
Specially Trained CNAs

15. BrightStar Clinical Pathways SM
 Heart failure
 COPD
 Pneumonia
 Acute MI
 Delirium & Dementia
 Diabetes
 Falls with Fracture

16. BrightStar Clinical Pathways℠ Materials

17. BrightStar Clinical Pathways ℠ :
Essentials Package
4 RN CPC Visits, 8 RN CPC Virtual Visits,
13 Specialty CNA Visits
Week 1 Week 2 Week 3 Week 4 TTL
RN Visit X X X X 4
RN Phone Call X X X X X X X X 8
CNA/HHA Visit X X X X X X X X X X X X X 13
25
Each face to face visit is a 2 hour condition-specific person-
centered interaction focused on empowering the client as well
as symptom surveillance

18. BrightStar Clinical Pathways ℠
MS DRGs and Frailty Factors
MS DRG MCC
*Frailty Factors
• Mult Diagnoses
Essentials
• Mult. Medications
MS DRG CC Plus • ADL/IADL Deficits
• Unintentional Wt Loss
• Limited Support
MS DRG Essentials
Frailty Factors*

19. BrightStar Clinical Pathways ℠ :
Essentials Plus Package
5 RN CPC Visits, 13 RN CPC Virtual Visits,
17 Specialty CNA Visits
Week 1 Week 2 Week 3 Week 4 TTL
RN Visit X X X X X 5
RN Phone Call X X X X X X X X X X X X X 13
CNA/HHA Visit X X X X X X X X X X X X X X X X X 17
35
Each face to face visit is a 2 hour condition-specific person-
centered interaction focused on empowering the client as well
as symptom surveillance

20. Other Essential Elements of
BrightStar Clinical Pathways℠ – Care Together
• Web based communication and calendar
tool for the client and their formal and
informal care team; also promotes the self-
management of chronic illness
Building a – PressGaney/Patient Impact
• National Patient Satisfaction Survey
Platform of comparable to what many hospitals
utilize
Clinical – We hold ourselves to a high service
standard
Excellence – 9 out of 10 clients would refer us to a friend
– ABS 2.0
• Data tracking of diagnosis, recent
hospitalizations, reasons for
admission/readmission;
• Staff assignment

21. ℠
Three key ways CareTogether enhances BCPs for clients & their families:
1. Condition specific
educational materials, care Families using with physicians and case
tools, resources managers can enhance communication
and understanding and adherence!

22. ℠
Three key ways CareTogether enhances BCPs for clients & their families:
3. Keeping the family involved
and updated is key part of
2. Calendar linked with ABS family and friends supporting
shows client + Care Team visit the care and “better choices” of
dates, times, name and more the Pathways program

23. HCAHPS vs BrightStar Press Ganey Survey
http://hcahpsonline.org/Files/HCAHPS%20V6%200%20Appendix%20A%20-
%20HCAHPS%20Mail%20Survey%20Materials%20(English)%202-16-2011.pdf
Discharge
Plan?
Which questions match between
HCAHPS & Press Ganey?
Which questions illustrate
opportunities for BrightStar to
help?

24. BrightStar Clinical Pathways ℠
Foundational Concepts
• Person Centered
– The individual is more than the sum of their parts
(or their diseases and medications)
• Patient Empowerment with
Self Management of Chronic Disease
• BrightStar Clinical Pathway℠ Team Leader
– Together
– Everyone
– Achieves
– More

25. Key BrightStar Clinical Pathways℠
Coordinator Goals
• Motivate Clients
– To become as independent as possible in monitoring
and maintaining their own health status
• Provide Clients with the knowledge and skills
– To make informed decisions about their healthcare
and quality of life
• Reduce negative outcomes
– Hospitalizations, Readmissions, Urgent Care Visits
,ER Visits, Falls, Med Errors, etc
• Maintain active communication
– BrightStar Clinical Pathway Team, Client’s Family and
Physician, Other Healthcare Providers

26. HF Visit Details: RN & CNA

27. HF Knowledge Guidebook

28. HF Red Flag Alert

29. HF Symptom Tracker

30. Benefit to Patient:
Continuous care for better outcomes
RN education
Earlier Discharge Reduce risk of falls
relationship
One on one help and Additional resources
Improved medication guidance in the home to provide care,
management from specially transportation, RX
trained CNAs pick up, cleaning, etc
Stay out the of
hospital and the ER

31. What this program will mean to
Healthcare Systems & Providers:
Better Patient
Outcomes Improve Efficiencies
Improved Identify high-risk patients
Communication Complements patient and
and target specific family preparation for
Improve flow of information interventions to mitigate discharge. Ensure a timely,
between hospital, their risks for adverse efficient and safe
0utpatient physicians and events. With timely post discharge and transition
provider. discharge in-home care to home.
management and follow
up.
Better Image
Improve patient and public Reduce likelihood of
perception of care and result in
higher satisfaction scores.
potentially
Promote customer loyalty &
confidence in St. Mary's and
preventable and
enhance patient overall costly readmissions
experience.

32. Why BrightStar?
Our Difference:
 Joint Commission Accreditation  Commitment to RN oversight
 Fully Licensed by the  Person centered approach
 Press Ganey satisfaction survey  CareTogether®
 Licensed and insured for transport  Flexible & responsive
 RN DON trains & competency tests
 Highly qualified and specially trained staff
all CNAs
 Stringent screening and employment
 All patients receive in-home risk
practices
assessment to help reduce falls
 HANDS
 Continuity of care and care
collaboration  BrightStar Clinical Pathways
 Ongoing services to maintain safety  Locally owned & operated
and success

33. Ask Me How We Can
Make More Possible For You!
Kym.Guy@BrightStarCare.com
805.358.6022