HomeCareCommunity.org's Page

In order to distinguish your homecare patients with Type 2 Diabetes who are at increased risk of developing other chronic diseases – such as heart disease, kidney disease, etc. – identify patients with one or more of the following risk factors within a particular time period:

• more than one HbA1C that is greater than 7% and/or
• LDL-C greater than 100 mg/DL and/or
• blood pressure readings of greater than 140/90 and/or
• individuals who smoke…

Three main areas or systems will need to be addressed in order to support accountable care objectives; care transition, coordination of evidence-based care and consistent reporting and communication.

Care Transition and Coordination of Evidence-Based Care

As the patient transitions from one care setting to another, it is important to address those areas that are often a concern, such as summary of care provided by previous setting, medications, follow-up with primary care…

The Quality Improvement Organizations 10th Statement of Work requirements, as they are applicable to health care associated infections, overlaps with at least one measure tracked by physicians, and could be a reason for hospitalization. Infections such as the following are cited (Federal Register, April 7, 2011 and Federal Register, November 2,…

Numerous quality measures for physicians are focused on disease processes such as diabetes mellitus, heart failure, and chronic kidney disease.  Screening or Prevention measures applicable to diabetes, mammograms, colorectal cancer screening, body mass index evaluation (a noted contributory factor to heart disease and diabetes) are also part of physician reporting.

For Medicare recipients receiving home care services between 1997 and 2009, diabetes and heart failure are the leading…