Longitudinal care: Providing care between home health visits and episodes of care

Longitudinal care: Providing care between home health visits and episodes of care

Care in the United States is largely episodic — you get sick, you seek care. And in most cases, patients and their families are left to manage their own health between these episodes of care. This often results in caregivers defaulting to treating the immediate problem at hand without full insight into the individual’s longer-term health challenges.

This poses a serious problem for patients, especially those enrolled in home-based care following a health event, who need access to relevant plans of care, timely access to professional care, and insights into their own health that are predictive, proactive and actionable.

For many elderly patients, the journey following an adverse event in healthcare will take them from the hospital, through a skilled nursing facility and back to the home with home health visits. In many of these cases, the family is forced to become the “source of record” — or the longitudinal memory — as these facilities are rarely connected and often paper-based. The result is the loss of critical information, along with lost efficiencies for the agencies themselves, as information must be reviewed and re-entered.

Access to historical information, both subjective and objective, helps family members and patients more quickly identify, assess and manage their own health. When coupled with emerging AI-based predictive tools that compare individual results with population-level data, it can also help improve proactive patient engagement and compliance.

In this blog, we define longitudinal care plans (LPCs), explore the benefits, and discuss the ultimate goal of patient and family engagement, treatment plan adherence and the management of chronic conditions between episodes of care.

What is longitudinal care in home health?

Longitudinal care in home health is essential for providing high-quality, patient-centered care that addresses the unique needs of individuals in their home environment, promotes continuity and early intervention, and empowers patients to achieve better health outcomes. It enables providers to deliver personalized care that is tailored to meet the unique needs and circumstances of each individual patient.

Key components of longitudinal care in home health include:

  • Regular assessments
  • Monitoring of vital signs and symptoms
  • Medication management
  • Coordination of services
  • Patient education and empowerment

By delivering care in the familiar and supportive environment of the patient’s home, longitudinal care promotes independence, enhances quality of life, and improves health outcomes for individuals with chronic conditions or those recovering from illness or surgery.

Why is longitudinal care beneficial to home health?

Longitudinal care promotes continuity of care, allowing healthcare providers to develop a deep understanding of the patient’s medical history, preferences, and unique needs over time. This familiarity enables more personalized and effective care delivery, as providers can tailor interventions to align with the patient’s goals and values.

By monitoring the patient’s condition regularly and observing trends over time, healthcare providers can identify subtle changes or emerging problems proactively before they escalate into more serious complications. This proactive approach not only helps to improve health outcomes, but also reduces the likelihood of unnecessary hospitalizations or emergency room visits.

It also promotes patient engagement and empowerment — as building long-term relationships with healthcare providers fosters trust and encourages patients to take an active role in managing their health. Patients feel more supported and motivated to adhere to treatment recommendations and adopt healthy behaviors when they have a consistent team of professionals guiding and supporting them throughout their health journey.

Why is patient and caregiver engagement important in longitudinal care in home health?

Longitudinal care is crucial for maintaining continuity and promoting the well-being of home health patients. Between scheduled visits, caregivers play a pivotal role in ensuring that patients receive consistent support and attention.

This approach requires three important elements to engage caregivers and empower patients — ultimately enhancing the quality of care and promoting better health outcomes for individuals receiving home-based care.

1. Communication

Effective communication serves as the cornerstone of care provision between visits. Caregivers should establish clear channels of communication with the patient, their families and the healthcare team to stay informed about the patient’s condition, progress, and any changes in their needs.

Regular updates allow for timely adjustments to the care plan and help prevent potential complications.

Whether through phone calls, emails, or secure messaging platforms, maintaining clear and consistent communication fosters collaboration and ensures that everyone involved remains informed and engaged in the patient’s care.

2. Education

Providing comprehensive education equips both professional and non-professional caregivers with the knowledge and skills to effectively manage the patient’s condition, administer medications, and recognize signs of deterioration.

Similarly, educating patients about their own condition, treatment plan, and self-care strategies promotes active involvement in their own health management, autonomy and self-efficacy — ultimately helping to promote better health outcomes.

3. Supportive environment

A supportive environment is essential for optimizing patient outcomes. This involves ensuring a safe and comfortable living space, providing emotional support, including families and non-professional caregivers in the episodes of care, and encouraging adherence to treatment recommendations.

Is your organization bridging the gap between episodes of care? Connect with us to learn more about incorporating a longitudinal approach into your care plans.

See what MatrixCare can do for you

Tim Smokoff

Tim is the General Manager, Home Health and Hospice, at MatrixCare. He is a seasoned healthcare leader, keenly focused on advancing data-driven technology solutions, driving operational excellence, and fostering strategic innovation. Building on more than 25 years of extensive success leading software operations, Tim guides the overall strategic direction and operational execution of MatrixCare's Home Health and Hospice business vertical.

Two office professionals looking at a laptop

See MatrixCare in action

Start by having a call with one of our experts to see our platform in action.