A Look into Care at HCR
Keeping your patients at home and healthyâ€”
We Can Do That!
TABLE OF CONTENTS
About HCR Home Care......................................4
Services and Locations.....................................5
When to Refer your Patients...........................7
Wound & Ostomy Care....................................15
100% Patient Satisfaction................................8
Provider Link Physician Portal.....................18
ABOUT HCR Founded in1978, HCR Home Care is a licensed and certified home health agency providing professional services and customized care to the residents of Upstate New York. Our clinical specialists, home health aides, and coordinators work closely with primary care physicians, care providers, and family members to form a continuum-of-care focusing on patient health. Combined with the latest technology, training, and health practices, our specialty services use current research in clinical practice to drive patient outcomes.
Local Professionals: • Skilled Nurses • Physical Therapists • Occupational Therapists • Speech Therapists • Medical Social Workers • Registered Dietitians • Home Health Aides • Personal Care Aides
Today, we care for patients in 19 counties from the shores of Lake Ontario to the North Country, employing over 750 local professionals dedicated to serving their close-knit communities.
Your home care solution across Upstate New York—
making a referral is easy! 4
Services and Locations Finger Lakes/WNY Region Central NY Region Catskill Region North Country Region
Specialty Care Programs:* • Cardiac Specialty Care/Heart
Failure Rehabilitation • Telehealth Monitoring • Joint Replacement Therapy • Falls Prevention • Stroke Rehabilitation • Transcultural Care • Hispanic • Russian • Ukrainian • African American • LGBT • Somali & Nepali • Diabetes Education and Management • Wound & Ostomy Care • Infusion Therapy • Parkinson’s Disease • Palliative Care • Veterans Care • Geriatric Care • Pediatric Care • Health Home Provider
Locations Throughout Upstate NY: Finger Lakes/WNY Region Monroe, Genesee & Orleans Counties (p) 585-272-1930 (f ) 585-672-2520
Central NY Region Cayuga & Cortland Counties (p) 607-299-4593 (f ) 607-299-4616 Jefferson, Madison, Onondaga & Oswego Counties (p) 315-280-0681 (f ) 315-280-0706
Catskill Region Otsego & Schoharie Counties (p) 518-254-7092 (f ) 518-823-4006 Delaware County (p) 607-464-4010 (f ) 607-464-4041
North Country Region Clinton, Essex, Franklin & St. Lawrence Counties (p) 518-310-0900 (f ) 518-310-0885 Hamilton, Warren & Washington Counties (p) 518-636-5726 (f ) 518-636-5727
Or call us toll-free at 800-270-4904!
*Contact your local HCR office to find out what services and programs are available for patients in your area.
Value Statement: Home Care Excellence that Embraces the Triple Aim Strategy for Improving Health Care
Our partners and customers across the health continuum and in the communities we serve will recognize our superior quality, focused effort to exceed expectations, and our commitment to continuous improvement. Our Brand of Care is patient-centric and supportive of provider efforts to collaborate and coordinate care to ensure health improvement to the population served.
1. Improving the patient care experience:
• Clinical expertise in home care innovation and quality • Expertise in effective care transitions to address complex issues and reduce hospital length of stay • Admission to home care within 24 hours of hospital discharge • Physical therapy available on weekends, including protocols for up to 5 days per week • Interdisciplinary and collaborative care team model • Field-based case management • 24/7 on-call nursing support • Employee-owners focus on excellence and patient satisfaction 2. Improving the health of patients and populations:
• Cultural competence is a cornerstone of our care model • Evidence-based disease management protocols focus on reducing preventable hospital readmissions • Specialist-led clinical programs and continuous education opportunities for staff • Telemonitoring is a standard of care for timely intervention to address changes in condition • Demonstrated history of superior outcomes compared to publicly reported benchmarks and other providers • Technology supports timely sharing of information with providers; a portal allows physicians direct access to patient EMR, and the ability to communicate with home care staff
• Data mining expertise offers providers and partners the granular information to support decision-making and evaluate care practice, outcomes, and cost
3. Reducing the cost of care:
• Pre-surgical visits for joint replacement patients to determine appropriate disposition post-op; emphasis on the most appropriate and the least costly setting for rehabilitation
• Leveraging “smart” technology to coordinate and schedule care, improve efficiency of care delivery, and support utilization of services to meet patient needs
• Demonstrated ability to prevent hospitalizations that result in higher cost and penalties to the health system • Expertise in successful management of diseases and populations associated with higher overall care • Sophisticated technology reduces waste and improves efficiencies in care delivery, emphasizing “right care/right time/right discipline”
When to Refer your Patients
Benefits of Home Care:
• A newly-diagnosed, change, or decline in condition
• Decreases hospital re-admissions
• Medication management needs
• Increases patient self-care management
• Unsteady gait, falls, or fractures
• Decreases office visits and phone calls
• Acute or chronic pain management
• Improves clinical outcomes of the patient
• Weight loss or nutritional issues
• Provides caregiver relief
• Mental status changes or depression
• Increases early identification of disease exacerbation
• Urinary tract infections or incontinence • Teaching needs—disease process, injections, I.V. therapy, etc.
• Therapy needs—physical, occupational, nutritional, and speech
• Joint replacement recovery and therapy • Unhealed wounds requiring management • Telehealth monitoring
Are Costs Covered by Insurance? Coverage is based on each individual case. Medicare, Medicaid, and most insurance plans are accepted. A nursing assessment can determine coverage. Refer your patients today!
• Frequent hospitalizations or ER use • Caregiver issues 7
100% Patient Satisfaction HCR Home Care strives to achieve 100% patient satisfaction. Our goal is to ensure your patients are completely satisfied with the care and services they receive from our agency. One way we measure our success on this initiative is through surveys. It is important that patients under our care are able to give us a score of “10” on a 0-10 scale. We value this feedback, and use it to help steer our efforts to consistently provide top-quality care.
“I was very pleased with HCR’s services. Each nurse and therapist was professional, friendly, helpful, and caring. I will definitely use this service again when I have my other knee replaced.”
“My experience with HCR was very positive. Every staff member was professional, knowledgeable, and courteous. I had a very good experience.”
“Our family wants to express our most sincere appreciation for the wonderful care you provided. Your staff always went above and beyond of what was expected of them to provide services.”
“My physical therapist was the greatest and best I have ever had for all previous needs. I felt I was in excellent hands with my rehab at home!”
“The HCR nurse and therapist were very bright spots in a rather painful situation. Their kindness and skill were way above expectations.”
“Everyone was very knowledgeable, helpful, friendly, and extremely professional. My first day at home was emotionally difficult for me, but your head nurse was so professional—she helped me considerably!”
Flora “You guys got me back on my feet. I haven’t had to go to the doctor’s once HCR started coming here. The aides I had were wonderful. They’re very helpful and you don’t have to tell them what to do. They come, they see, they do.”
Andrea “HCR has been our saving grace!”
A GLIMPSE INTO VARIOUS
Specialties, Programs & Tools AT HCR HOME CARE
As a leader in transcultural care, we understand and recognize cultural preferences regarding health care. HCR will respect and support your patients’ family traditions, religious beliefs, cultural practices, and facilitate personal language requirements. Our specially trained, culturally competent team of skilled health care professionals utilize evidence-based practices to provide all patients with the quality care and independence they deserve.
Transcultural programs: • Hispanic • African American • Russian • Ukrainian • Refugee • LGBT • Somali & Nepali Initiative
Language services: • Spanish • Ukrainian • Russian • French • Italian • German • Vietnamese • American Sign Language (ASL)
The Human Rights Campaign has awarded LGBT Healthcare Equality Leader status to HCR. Our LGBT program promotes the health and well-being of the LGBT community through the delivery of high quality, culturally appropriate home health services. HCR’s dedicated multidisciplinary staff has been certified in LGBT Cultural Competency by the Gay Alliance of the Genesee Valley.
One-third of all people over the age of 65, and half of all seniors over the age of 80, fall every year resulting in serious and debilitating injuries. The HCR Falls Prevention Program can dramatically reduce the risk of falling and subsequent injury. HCR’s multidisciplinary team of physical therapists, occupational therapists, and registered nurses will identify risks for falling, and develop a personalized plan to help reduce those risks and strengthen mobility.
HCR’s interdisciplinary Falls Prevention Team has experience determining a patient’s falls risk. • An individual screening using a “Gold Standard” tool determines the level of falls risk.
• After a comprehensive examination, we work with physicians to reduce an individual’s unique potential to fall.
• HCR will recommend safety equipment, like grab bars, to reduce the risk of falls, so patients can remain safely at home.
Clinical techniques include: Medication review, environmental modification, cognitive and perceptual training, and strength and reaction time training. Refer your patients to HCR for a falls assessment today. Triggers include: • Falls risk screening • Change in gait • Recent or past falls
Leading the way... HCR’s specialized cardiac team consists of a nurse practitioner and registered nurses with over 20 years of experience. We will transition your patients from hospital to home, provide teaching and management of their symptoms, and work with medical providers to help prevent hospital re-admissions and emergency room visits. HCR is able to keep Class III and IV CHF patients with recurrent hospital re-admissions at home through IV Lasix dosing, telehealth, and close monitoring. Our cardiac team regularly communicates with the patient’s medical team and provides intensive case management.
Each patient is assigned a cardiac nurse to provide close oversight of: • Sliding scale Lasix • Blood pressure management • Specialized vascular access • Remote telemonitoring • Post CABG and valve repair/replacement • Implantable cardiac devices • Post ablations
• Post PCI • Life vests • IV medication management at home • IV drips • High risk patients (including required cardiac drips) • LVAD • MI
HCR’s physical and occupational therapists assess blood pressure, pulse rate, oxygen saturation, and respirations for each patient on every visit. Peak exertion measures are monitored to ensure therapeutic exercises are delivered within acceptable parameters. HCR therapists closely monitor symptoms and changes in status, and communicate closely with the physician and RN case manager to ensure health status stability, thus minimizing risk for hospitalization.
Don’t wait, refer your patients to HCR’s Cardiac Care program today. 12
HCR Home Care has a Telehealth Program to enhance the care provided by HCR clinicians, improving quality health outcomes for your patients. Using telemonitoring equipment, we can:
• Increase early identification of disease exacerbation • Reduce re-hospitalization and emergency room visits • Improve self-care management
Why use Telehealth? We have dedicated registered nurses and telehealth specialists on staff, seven days a week, to review your patients’ data. Working with you, we establish patient specific baseline monitoring parameters. These include: vital signs, weight, oxygen saturation, and blood glucose levels. With your guidance, we establish acceptable interventions to address urgent issues:
• Telehealth nurse makes initial contact with patient to determine further action • HCR clinician will visit the patient if further assessment is needed • Clinician determines if physician intervention is required based on predetermined interventions • Customizable patient reports will be provided based on your preference
When to Refer to Telehealth? • Adjustment of medications
• Diabetes, newly diagnosed or unable to self-manage
• Uncontrolled hypertension/hypotension
• Any health condition requiring regular monitoring
Palliative Care This program is designed to improve quality of life at any stage of disease progression. Specially trained (ELNEC) nurses guide an interdisciplinary team to answer questions, educate, and manage pain, anxiety, respiratory difficulties, and other symptoms. Our goal is to support patients and caregivers living with a serious illness.
Program Goals Include: • Symptom Management • Assisting patient and family to understand and complete advanced directives • .Reducing stress and anxiety for the patient and family, easing caregiver and patient concerns • Addressing patient needs in the physical, psychological, emotional, and spiritual aspects of care • Ensuring access to information and counseling regarding patient options to encourage informed decision-making
• Reducing the frequency of hospital visits • Empowering patients and families to take lead in their care • Educating patients and families to understand their disease progression • Collaborating with providers to ensure a smooth transition of care across care settings • Having an on-call nurse 24-hours a day to answer questions, educate, and facilitate symptom control • Medical Director program oversight
When to Refer to HCR’s Palliative Care Program: • Concerns with serious and/or chronic illnesses • Poorly controlled symptoms • Caregivers requiring education and support • End-stage disease management
Wound & Ostomy Care Our Wound and Ostomy Team provides postsurgical and chronic wound care under the supervision of Certified Wound, Ostomy, Continence Specialists (CWOCN). These highly trained registered nurses (WOCN) and LPNs (WCC) have achieved national certification in wound, ostomy, and incontinence care. Our goal is to prevent complications while promoting recovery and independence.
Offering the education, guidance, and technology to effectively manage wounds by: • Teaching and promoting healing and care for wound and ostomies. • Advising on the best techniques and products to use. • Using digital photography to document wound progression to effectively communicate with physicians. • Consulting on appropriateness of patients for alternative wound therapies such as vacuum-assisted wound care, sharp debridement, and hyperbaric therapy.
• Interdisciplinary, comprehensive approach to the management of wounds.
When to Refer to HCR’s Wound & Ostomy Program: • All types of ostomies • Surgical incisions or wounds • Burns • Cellulitis • Diabetic ulcers • Lower extremity ulcers • Pressure ulcers • Skin breakdown related to an injury or fall
Whether your patient is recovering from surgery with a serious wound, learning how to manage a chronic wound, or how to live with an ostomy, our clinical experts are here for you! 15
HCR’s multidisciplinary team includes physical therapists, occupational therapists, and speech language pathologists. Our therapists use evidence-based assessments and techniques to identify the functional goals of their patients, while working directly with physicians to develop personalized plans for improvement.
Advanced specialization in the following areas of clinical practice:
HCR Therapists are among the most highly trained in the home care industry:
• Rehabilitation following joint replacement
• Doctorate of Physical Therapy (DPT)
• Prevention of falls
• Geriatric Certified Specialist (GCS)
• Dynamic balance training
• Certified Exercise Expert for the Aging
• Restorative therapy following stroke • Management of Parkinson’s disease • Adaptive training for low vision • Functional activity progression following heart
• Neuro Developmental Technique (NDT) for stroke recovery
• LSVT BIG Certification for Parkinson’s disease
Pain Management The multifaceted implications of pain often respond most effectively to a multidisciplinary treatment plan. The most successful approach often results from a physician-directed plan that involves a combination of both medical interventions and complementary disciplines such as physical therapy. The main objective of the Pain Management Program at HCR is to create an environment of healing for the patient. Success is defined by a patientâ€™s ability to perform functional tasks that were previously difficult or impossible. In addition, success can be established by a patientâ€™s decreased reliance on pain medications. This specialized care has proven to be highly effective within the patient population at HCR.
This program addresses pain syndromes using the following multifaceted approach: Patient Education: Patients respond to treatment when they clearly understand both the pathology and the associated treatment plan. Self-Empowerment: The program encourages success-oriented functional retraining strategies that focus on pain-free movement and decreased anxiety. Self-Treatment: Clinicians assist the patient in designing and monitoring a home exercise program that he/she is able and willing to perform. Physical Therapy Treatment: The program includes a combination of modality and manual therapy interventions that assist in breaking the cycle of pain.
Provider Link Physician Portal
Provider Link gives physicians and staff secure online access to real-time information about the patients they’ve referred to HCR Home Care.
Review Home Care Orders
Secure, Confidential, and HIPAA-Compliant
Approve, decline, and sign home care orders. Make notes for changes to home care plans.
Create a secure and confidential compliant environment that is so simple to use, even tech-wary users can see its benefit.
View Patient’s Entire Home Care Episode
View vital statistics and charts, diagnoses, medications, wound histories, and outcomes.
Provider Link comes at no cost to you.
Contact your HCR representative to enroll in Provider Link today! 18
A comprehensive guide to the programs and services offered at HCR Home Care.