Chronic Disease Care

A New Mindset for Home Care

The typical Appalachian Community home care client is 71 years old, was referred to us by a hospital or long-term care facility, has a history of multiple hospitalizations, is on five or more medications, requires the assistance of another person to remain at home, and has diabetes and cardiac disease.  In addition, 22% of our clients have respiratory disease and are on oxygen therapy, 47% have impaired mobility, 33% have a urinary catheter, and 16% have chronic pain.

So what are we doing about chronic disease management? The center of attention in home care is shifting from that of “treating” or “palliating” acute conditions to that of the spectrum of chronic care. Chronic disease is, in fact, at the heart of the vast majority of our care, and several new approaches to respond to this situation are being developed.

It is a different mindset and one that we at Appalachian Community are embracing. We are currently exploring certification in chronic care for all of our clinicians. Not only will this affect our daily practice but, in the future, reimbursement as well, as “bundling” and closer partnerships between home care, physicians, hospitals, and longterm care facilities become the new norm.

It is now being recognized that chronic care management models must support the individual in the environment where they face their daily challenges – their home!