American Angels Home Care is a program based, Medicare certified, care at home organization. We provide both skilled and non-skilled care programs. Unlike most traditional home health care agencies who subscribe to the one size fits all, discipline based (nursing, therapy, etc.) approach, also known as “islands of care” approach; at American Angels Home Care, we subscribe to the program based (CHF program, Total Joint Program, etc.) approach to care at home. This approach is also known as “coordinated care at home” approach. Our patients do not get just nursing, physical therapy, etc. like other agencies do. Our patients get a custom plan of care, developed by a care team, that is patient specific.
The Program Based Approach:
When a patient is admitted to our agency, he or she is also simultaneously admitted to a program of care (i.e. the Stroke/Speech pathology program). Each program has a clinician from each discipline (a registered nurse, a physical therapist, an occupational therapist, a Speech therapist, a Medical social worker, and a Home health aide). While treated in the program, the patient is assigned a case manager who is responsible for that case and coordinates the care between the various disciplines. Case Managers are assigned to cases, based on the patient’s primary diagnosis, active health problem, and the focus of plan of care (POC).
Outcome Based Home Care:
Having customized programs of care allows us to focus on patient outcome. We measure outcome on every visit and during each follow-up nursing assessments and therapy evaluations. Our clinicians are rewarded based on positive patient outcome and our compensation model is based on reaching defined outcome benchmarks. We call it “rewarding the healers”.
Hospital Readmission Reduction Program:
By far, we have the most robust hospital readmission reduction program (HRRP), in southeast Michigan. Acute Myocardial Infraction (AMI), Congestive heart failure (CHF), Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), and Urinary Tract Infection (UTI), are the five most leading causes of hospital readmissions in the United States. Our program focuses primarily on those five conditions. We developed a disease-specific program for each on of the five conditions, with dedicated teams. The HRRP manages the effectiveness of these programs as it relates to readmission rates. All programs work together under the HRRP and share best practices on how to reduce readmissions. HRRP goals are set on a monthly basis and all teams work separately and collectively toward those goals. As a result of the HRRP being in place, our hospital readmissions have remained well below the state and national average for the past three years.