Empowering Patients and Improving Outcomes with CenterWell Home Health’s Advanced Clinical Programs

Sherri Rains, RN, CWOCN, Chief Clinical Officer, CenterWell Home Health

By Sherri Rains, RN, CWOCN, Chief Clinical Officer, CenterWell Home Health

Medicare spends an estimated $17 billion or more on unplanned hospital readmissions each year, many of which occur within 30 days of discharge. A critical factor in reducing readmission rates and health care costs is continuity of care when the patient returns home from the hospital. For optimal transitions, it’s essential for home health providers to tailor care to each patient’s specific needs. However, what’s often missing is the integration of specialized programs that not only address a person’s unique health circumstances, but also educate patients on tools and techniques that will enable the successful self-management of their condition.

At CenterWell Home Health®, we’ve developed research-based advanced clinical programs to address the complex conditions most frequently treated in the home setting, including diabetes, heart failure and open wounds, as well as the factors that increase fall risks. A cornerstone of our approach is the specialized training in evidence-based best practices every clinician within our multidisciplinary team receives in clinical programs that address each of these four conditions. This ensures a high level of care from all clinicians treating our home health patients. It also enables more comprehensive care since patients are often dealing with more than one of these conditions.

For instance, while an individual is receiving post-acute care for heart failure, the underlying problem may be uncontrolled diabetes, which can also contribute to poor wound healing and neuropathy that increases fall risks. Clinicians trained to assess and treat multiple medical conditions, with access to information and resources to educate patients about their health, are better equipped to deliver effective and preventive care.

The clinical team is further supported through an electronic playbook allowing clinicians instant access to advanced clinical program information and resources that may be needed as they care for patients.

While there are commonalities in the way we approach the care of all our patients, CenterWell Home Health’s advanced clinical programs are grounded in research that very specifically informs our training and clinical practices for each of our programs: Daily Difference with Diabetes™, CenterWell Keeping Hearts at Home™, PRIME Wound Care® and Safe Strides®. Using a data-driven process also allows us to assess our programs continually and make modifications as evidence evolves.

Daily Difference with Diabetes

The prevalence and costs of diabetes, as well as the impact it has on those with the condition, make it one of the most challenging problems in health care today. More than 38 million Americans have diabetes, including 30% of older adults. Medical costs associated with diabetes reached almost $307 billion in 2023.

Evidence shows that self-management education and support improves diabetes outcomes and reduces hospital admissions and readmissions. Our Daily Difference with Diabetes program, recognized by the American Diabetes Association (ADA) for Quality Self-Management Education and Support, utilizes proven behavioral modification strategies to help patients manage their diabetes in addition to clinical oversight. If adequate progress isn’t being made through lifestyle changes, our clinical staff works closely with the patient’s physician to determine the need for a medication change.

This program is making a real difference for patients, as 75% report feeling more confident in their ability to manage their condition and nearly 90% have improved management of their oral medications.

CenterWell Keeping Hearts at Home

Heart failure is the number one cause of hospitalizations in the Medicare population. There are nearly one million new heart failure patients each year and one-third are hospitalized within 30 days of diagnosis.

Among those heart failure patients was Gadine A., who had been an active and independent 83-year-old in Kansas, but her heart condition led to massive swelling in her legs, which left her in a wheelchair and house-bound. She credits the care she received from CenterWell’s Keeping Hearts at Home program with getting her back on her feet and enjoying life again. With the help of CenterWell nurse Becky Hutchinson, RN, educating her about her condition, along with close monitoring, Gadine made changes in her medication and improvements in her diet and exercise routines that reduced the swelling and pain she was experiencing.

Swelling from fluid retention and shortness of breath are two common symptoms that frequently land heart failure patients back in the hospital and are often part of a vicious cycle. Intake of too much sodium and fluids, lack of regular or proper use of medications, as well as limited physical activity, can increase fluid retention that can cause difficulty breathing, which, in turn, limits physical activity.

Centered on disease process assessment, medication management and education, CenterWell Keeping Hearts at Home has improved management of medication among 92% of patients in the program, and that same number reported improvements in shortness of breath.

PRIME Wound Care

Chronic and severe wounds disproportionately afflict older adults and are often caused by vascular disease, venous insufficiency, unrelieved pressure and diabetes, as well as from surgical incisions that don’t properly heal. In fact, 1.6 million older adults have open wounds that, if not properly cared for, can cause severe infections, illness or even sepsis, which is the leading cause of unplanned hospital readmissions and their associated costs.

To prevent these complications, PRIME Wound Care is a comprehensive approach that includes prevention, intervention, management and education (PRIME). CenterWell Home Health clinicians receive extensive training in the etiology of wounds and best practices in addressing the various factors preventing proper healing. Our Wound Treatment Associate Program offers an opportunity for clinicians to advance their career development in wound specialty. Right now we have 162 Wound Treatment Associates in the field to provide critical wound education and guidance for direct care clinicians.

For particularly high-risk and difficult cases, CenterWell initiates its Wound Escalation Process, in which our team of Certified Wound, Ostomy, and Continence Nurses provide oversight and consultation. The program is further supported by an AI-driven wound management system that takes pictures and measurements of the wound to enable monitoring and assessment of its progression. The tool enhances visibility and enables a more efficient response time, as well as prompting higher level interventions when problems are detected.

Safe Strides

Falls are the leading cause of injury for adults 65 years and older, with one in four reporting a fall every year (most occurring in the home) resulting in three million ER visits and one million hospitalizations. In 2020, medical costs attributed to non-fatal falls was $80 billion.

Providing care in the home enables our clinical teams to understand the patient’s environment. Safe Strides is a one-of-a-kind prevention program that takes a multidisciplinary, comprehensive approach to fall risk management and gets to the root of the problem. Therapists assess various balance systems, including visual, vestibular, somatosensory and musculoskeletal, to provide targeted interventions. Among the patients in the Safe Strides program, 93% showed improvement in six functional assessments that included some basic daily activities.

Win W. was one of the patients in the program who made remarkable strides. At 86 years old and legally blind, he was engaged to be married but had broken his hip from a fall before the wedding. He told his therapist his goal was to dance with his new bride on their honeymoon. Because of his determination and hard work, and the intensive physical and occupational therapy and support he received, he was able to travel with his wife to Santa Fe where they danced together.

CenterWell Home Health’s advanced clinical programs make a real difference in the lives of our patients. Their improvements and satisfaction with their care are reflected in the high Quality of Patient Care Star Ratings we receive from the Centers for Medicare and Medicaid Services (CMS)—with an average of 4.29 as of July 2024, well above the 3.25 average for the industry as a whole. As part of CenterWell’s home health services, these advanced clinical programs enhance patient outcomes through specialized, research-driven care that promotes greater independence and well-being in the comfort of one's home.

To learn more, visit CenterWell Home Health.