HOMECARE HEALTH SERVICES

Tel +971 2 634 6431 Fax +971 2 634 6413 PO Box 128217 Abu Dhabi, UAE Website: www.phs.ae رقم الهاتف: ٤٦٣٩ ١٧٩ ٢ ٤٣٦ رقم الفاكس: ٤٦٩٣ ١٧٩ ٢ ٤٣٦ ص ب ٢٨٢٨٢١ أبو ظبي اإلمارات العربية المتحدة الموقع: www.phs.ae Consultancy for Healthcare Facility and Clinic Services Homecare Health Services Ambulance and Patient Transfer Medical Staff Provision Continuous Medical Education HOMECARE HEALTH SERVICES Professional Staff Infrastructure Homecare Health Services Policies Procedures Guidelines Quality care in the comfort of your home Documentation & Reporting INTRODUCTION As today s technology becomes far advanced, so are debilitating diseases afflicting people from the culturally diverse and highly industrialized emirate of Abu Dhabi. The local government invests a great deal on the design of its thrust programs equipped with sophisticated system and infrastructure to boost productivity rates and enhance quality of outcomes. Cognizant of the influence of its workforce on exponential growth, it makes certain that its residents gain access to equitable and quality health care, especially in the course of their employment. While it holds true that the efforts people put in are remunerated well based on the mean salary for skilled workers in the region, it is likely that there is as much health risks as there are work benefits. Exposure, for instance, over a protracted time period to workplace hazards coupled with unhealthful lifestyle choices is associated with the development of cardiovascular, neurologic, endocrine, and oncologic cases based on recent epidemiologic reports of Page 1 of 25

Health Authority Abu Dhabi (HAAD, 2011). The financial and emotional burden of these on the economically productive group is compounded further by the latter s need to assume equally significant roles in the home, like taking care of the young ones and the very old or ailing members of the family. Albeit confinement to medical facilities would afford them security and convenience on account of health resources, it does grab them of the opportunity of being able to share quality time with the people close to their hearts. The in-patient services, however, may not be as cost-effective as it is when patient is brought home along with the medical assistance he would need during rehabilitation. The growing demand for the continuity of care following hospital discharge and for greater collaboration among health personnel creates the urgency for homecare health services (HHS). HAAD feels strongly that encouraging home-specific strategies devised by private sectors is essential to achieving the health targets set forth and, on a bigger scale, setting the future directions of the Emirate. PHS CUTTING EDGE In consonance with HAAD s sound philosophy and objectives, the Pyramids Health Services (PHS) is truly passionate about helping deliver client-focused homecare services, which essentially cut down healthcare cost and add value to patient care. Expounded below are the salient points of HHS program: Brings families together. This is particularly important in times of illness when families desire to be near one another for support. Home care is a comforting alternative to premature admission to a long-term care facility. Since most people would prefer to stay in their own homes as long as possible, home care can provide services tailored fit to client s needs. Page 2 of 25

Promotes healing. There is scientific evidence that many patients heal faster at home. It also prevents unnecessary visit to ER and hospital clinics after discharge. Safe. Risk for infection is reduced significantly and its spread controlled more easily and effectively in the home. Early intervention and visit reduce disease complications. Promotes continuity of care. Patient s own physician continues to oversee his or her care. Home care is personalized or customized to individual needs. Patients receive one-on-one care and attention. Less expensive. If skilled care is not needed around the clock, home care allows for creating individualized care plan that surely meets patient s needs and considers the budget or health financing. In fact, the cost of having a visiting nurse is much cheaper than the hospital fee during confinement. The preferred form of care. Studies show that 95 percent of those aged 75 and older would love to stay, as much as possible, in their current residence while receiving treatment or care. Provides for greater degree of freedom and privacy. Patients at home remain active in their customary or daily routines within their comfort zones, free from worries or irritations brought about by immediate environment. Page 3 of 25

MEDICAL BACKGROUND The figure below depicts the pyramidal distribution of the 2.4-million people in the Emirate of Abu Dhabi. One in five residents (or 18 percent) are Nationals, of whom two thirds are under 30 and half under 19, around which the median age falls. The combined population of both the locale and foreign residents forms a symmetrical base, representing those younger than 20. At its center lies a broad configuration skewed largely to the right, corresponding to expatriates, mostly male and of Asian origin, in their economically productive years (20 to 40). The acme, on the other hand, is reflective of those who are nearing or who may have in fact gone beyond the life expectancy at birth reckoned between 74.9 (for males) and 77 years (for females), respectively. Figure 1. Population by age, gender and nationality (HAAD Health Statistics, 2011) Abu Dhabi s population has demonstrated steady increase since 1999 at a rate of 5.5, with a significant decline noted in the year 2009. While the fertility rates the main driver of growth for Nationals have diminished from 4.4 to 2.3 per woman between 1990 and 2007, the mortality rates have lowered as a confluence of the robust implementation of health ministry s thrust programs and Page 4 of 25

services. The resultant decrease in the birth rates, however, are thought to have stemmed from urbanization, delayed marriage, changing attitudes about family size, and increased education and work opportunities for women. In addition, the World Health Organization has reported a marked decrease in the Under 5 Mortality from 15 to 7 per 1,000 live births between 1990 and 2009. The diseases of Circulatory System, on the contrary, ranked as the leading cause of deaths in 2011, accounting for 37.50 percent of all death cases registered, followed by the external causes of morbidity and mortality and neoplasms. Road traffic accidents involving young males and occupationrelated injuries have been identified as root of such demise. Interestingly, the preliminary analysis of the Weqaya screening on 112,301 UAE Nationals from 2008 to 2009 revealed that 71% had at least one CVD risk factor. Many were unaware, thus unable to seek care. The following risk factors were projected to increase through time: obesity, hypertension, diabetes, high lipids, and smoking. Figure 2. Correlation among selected cardiovascular indicators (HAAD Health Statistics, 2011) In lieu of the foregoing statistics, lifestyle-related conditions such as Diabetes mellitus and Cancer remain as one of the prevailing public health concerns. Government attempts are aimed at preventing these diseases from occurring at the outset by working with a range of stakeholders. One creative Page 5 of 25

solution that the regulatory body recommends is treating patients, particularly those who are frail, in their homes. It is therefore the agency s desire that they are treated outside hospital wherever possible; their care communicated clearly and timely through proper channels while the latter is transported to the appropriate facility by means feasible, i.e. land or air. Note: Risk of diabetes is defined as HbA1c > 6.1% Figure 3. Prevalence of Diabetes by age group (HAAD Health Statistics, 2011) Figure 4. Cancer death cases group (HAAD Health Statistics, 2011) Page 6 of 25

HAAD s end-view of world-class quality care and outcomes in compliance with the highest international standards can be achieved through the full spectrum of health protecting, promoting, sustaining and restoring services. Through the mandatory health insurance initiated in 2007 and with residence status being generally contingent on being employed, everyone in the Emirate of Abu Dhabi gains access to healthcare and enjoys freedom to choose his/her provider. Page 7 of 25

PHS HOME CARE FRAMEWORK Corporate Team Professional Staff Medical Professional - Geriatric specialist - Pediatrician; neonatologist - Senior general physician - Nurses (general and specialized) - Physiotherapist - Diagnostic Technician - Psychologist; psychotherapist - Infection control personnel Non-medical Staff - Medical Director - Nursing Director - Quality Assurance manager - Health and Safety officer - Social worker - Insurance coordinator - Finance manager - Marketing manager Infrastructure Homecare Health Services Medical Reporting Policy Procedures Guidelines Page 8 of 25

* Duties of Healthcare facilities and professionals Reporting health statistics Submitting data to HAAD via e-claim Standards and procedures: http://www.haad.ae/datadictionary/routinereporting http://www.shafafiya.org/dictionary/portal/ Providing treatment and care services In accordance with rules on authorization rules and regulations, healthcare professionals and staffing specifications and eligibility criteria and UAE Federal Law No 7 (1975) Managing patient medical records Including requirement for patient confidentiality, patient records and information technology and data management Reference: HAAD Standard for Authorization of Homecare Health Services in Emirate of Abu Dhabi. (June 2011), FACL/HSF1.2, Version 1. 3. Infrastructure Medical Equipment & Instruments - emergency kit, dressing bag, monitors, nebulizers, oxygen cylinders, infusion pumps, etc. Transport Vehicles - Ambulance: fully equipped to facilitate safe transfer - Paramedics: with BLS and ACLS training certificate - Drivers: with experience & training on emergency Hospital Management Information System One Bag - One Clinic (OBOC) General nursing Special wound care Blood sampling and transport Page 9 of 25

Policies, Procedures, and Guidelines Referral Claim management Evidence of referral policy for laboratory services Emergency action Medical equipment management Medical waste management Patient transport Infection control Patient s rights and responsibilities Medication management Patients record Medical Records, Forms and Reporting Clinical and audit reports Statistical analysis Regular meetings with referring physician Page 10 of 25

Patient Care Plan using Care Domains (Blueprint/Template) Care Domain Details Care Provider Time frame Resources 1. Medication; symptom control 2. Pain management 3. Nutrition 4. Mobility 5. Dialysis care 6. Continence, including catheter and stoma care 7. Skin integrity; wound care 8. Clinical investigation 9. Others (as detailed in clinical service line) 10. Communication and speech therapy Reference: HAAD Standard for Authorization of Homecare Health Services in Emirate of Abu Dhabi. (June 2011), FACL/HSF1.2, Version 1. 3., Appendix 1. Patient Referral/Handover; HC Provider Responsibilities (Template) Responsibility Activity Referring Provider Receiving Provider 1. Decision for referral 2. Provider capacity for care 3. Care plan 4. Equipment / consumables 5. Transport 6. Assessment of patient home environment / needs 7. Installation and setup of equipment or environment Reference: HAAD Standard for Authorization of Homecare Health Services in Emirate of Abu Dhabi. (June 2011), FACL/HSF1.2, Version 1. 3., Appendix 2. Page 11 of 25

Referral and Discharge Summary Reference: HAAD Standard for Authorization of Homecare Health Services in Emirate of Abu Dhabi. (June 2011), FACL/HSF1.2, Version 1. 3., Appendix 3. HHS PATIENTS Page 12 of 25

HHS CRITERIA To qualify for HHS, the patient must fulfill the following basic requirement: Physician referral with clearly defined patient care plan Client and/or family consent for care Unable to attend regular outpatient services due to immobility caused by chronic illness or other reasons Care requested is medically reasonable or necessary, and requires medical or nursing intervention for: - Terminally ill patient requiring palliative care for pain or symtom managment - Short-term assistance following day surgery, routine post-op or procedural follow-up, e.g. wound care, physiotherapy - Patient unable to mobilize safely without the need for complex and costly support or where HCF resources are not able to reasonable support clients' needs safely Reference: HAAD Standard for Authorization of Homecare Health Services in Emirate of Abu Dhabi. (June 2011), FACL/HSF1.2, Version 1. 3. For peritoneal dialysis services and pain management using controlled medications at home, the following would be essential: - Special request seeking authorization - Evidence that the HAAD licensed professionals providing the service have successfully completed certified training and have certification/accreditation and that they work within their scope of practice and the scope of service. - Evidence that the facility is equipped to provide 24-hour emergency support or intervention for acute symptom management and/or admission to an appropriate in-patient setting. NOTE: Authorization process is completed within 3 weeks from its submission date. The effectivity date is the same as the date of approval by HAAD; such authorization is subject to renewal at the time of facility s license renewal. Page 13 of 25

SERVICES The Health Authority Abu Dhabi (June 2011) stated explicitly the standards for Authorization of Homecare Health Services in the Emirate of Abu Dhabi to optimize successful discharge to homecare services and minimize risk of readmission. Consistent with its definitions and parameters, the Pyramids Health Services provide the following treatment or support to ensure quality, safe and accessible clinical care for patients: Screening o Taking of blood and/or tissue samples for a range of HAAD-specified tests, i.e. Weqeya (Arabic for protection ) o Follow-up services Clinical treatment services - Provided by licensed physician including: o Physician consultations (prior to discharge, in the home, telephone) o Plan of care, development, management and evaluation (NCP) o Assessment, evaluation, treatment, management and follow-up o Prescription, replacement and refill of medications o Prescription of medical supplies and equipment o Home preparation to assess environment and set up equipment where required o Home visit for prenatal, postnatal and newborn evaluation and management for evaluation and management of peritoneal dialysis for evaluation and management of pain complex wound care sharp debridement o Education and counseling consistent with the type/nature of treatment and/or care management needed Page 14 of 25

- Provided by licensed nurse including: o Management and evaluation of patient care plan o Observation and assessment of patient s condition, vital signs assessment o Administration of medications and instruction on Medication including but not limited to injections, IVs, inhalation, oral, Infusions, Rectal, and Enterals o Management of palliative care patients who have a diagnosis of cancer or advanced progressive illness/terminal life threatening disease of disabilities, including pain management o Daily insulin injections, supervision of patients with diabetes and monitoring blood glucose o Tube feeding management o Nasopharyngeal and tracheostomy aspiration o Indwelling catheter care and maintenance o Wound care o Ostomy care and maintenance o Assessment for oxygen therapy requirements o Venipuncture o Assessment and administration of peritoneal dialysis Point of Care Testing, including but not limited to: Blood Glucose Level; INR; Disptick Urine; I-Stat o Nasogastric tube care and maintenance o Foley Catheter Insertion o Pain management o Continence assessment and management o Prenatal, Postnatal and newborn assessment o Education and counseling, consistent with the type/nature of treatment and/or care management need Page 15 of 25

Support services - Provided by licensed professional according to specialty: o Psychotherapy o Occupational therapy o Speech therapy o Nutritional and dietician services o Education and counseling consistent with the type/nature and/or care management needed o Laboratory specimen collection o Physical therapy o Respiratory therapy o Clinical pharmacist for complex medical management and consultation o Social worker assessment, consultation and evaluation o Others: transportation of personnel to and from patient s home o Setting up of equipment, special bed; telephonic consultation and transportation Patient s rights - Compliance of healthcare provider with the HAAD Patient Rights and Responsibilities Policy and Charter - Culturally and socially relevant patient information and education in support of clinical services, consistent with relevant HAAD policies and standards Quality Management and Training - Internationally recognized best practices Periodic review and documentation of quality and safety of patient care, adjusting the procedures as necessary. Page 16 of 25

HHS COORDINATION TIER This tool can be used in the triage or clustering of patients and in determining the seriousness of their present ailment based on duration, severity, and effort required of the health personnel given the medical resources and technology. Further, this will be instrumental not only in obtaining the overall complexity of the case or in ensuring an accurate medical billing, which runs parallel with the approved payment scheme, but also in shaping the homecare health programs and coordination agendas. Page 17 of 25

CLINICAL CARE PATHWAYS Reference: HAAD Standard for Weqaya Follow Up for further diagnosis, treatment and management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 6. http://www.haad.ae/haad/linkclick.aspx?fileticket=cqvs63zbwt8%3d&tabid=634 Page 18 of 25

Reference: HAAD Standard for Weqaya Follow Up for further diagnosis, treatment and management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 7. http://www.haad.ae/haad/portals/0/diabetes%20flowchart%20june15-09.pdf Page 19 of 25

Reference: HAAD s Standard for Weqaya Follow Up for further diagnosis, treatment and management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 8. http://www.haad.ae/haad/linkclick.aspx?fileticket=xxdpv_kzpqe%3d&tabid=634 Page 20 of 25

Reference: HAAD s Standard for Weqaya Follow Up for further diagnosis, treatment and management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 9. http://www.haad.ae/haad/portals/0/hypertension%20june15-09.pdf Page 21 of 25

Reference: HAAD s Standard for Weqaya Follow Up for further diagnosis, treatment & management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 10. http://www.haad.ae/haad/portals/0/dyslipidaemia%20june15-09.pdf Page 22 of 25

Reference: HAAD s Standard for Weqaya Follow Up for further diagnosis, treatment and management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 11. http://www.haad.ae/haad/portals/0/high%20cvd%20risk%20june015-09.pdf Page 23 of 25

RISK CATEGORY FOR WEQAYA FOLLOW UP APPOINTMENTS Reference: HAAD s Standard for Weqaya Follow Up for further diagnosis, treatment & management of Cardiovascular Disease Risk Factor (June 2011), PHP/PHPr/WFU1, page 12. Page 24 of 25

PAYMENT MECHANISM Step 1 Eligibility for Health Insurance criteria must be established prior to admission to Homecare Health Service Program, including: Thiqa holder for nationals Other nationalities, only if appropriate supporting documentation is provided and as per health insurance product. Health Insurance as per Abu Dhabi regulations Health Insurance for services outside the scope of Abu Dhabi regulations Pre approval from Insurance company, before initiating the service. Step 2 All services and codes provided in support of approved clinical services under this Standard are reimbursable under the health insurance scheme in accordance with the client's health insurance plan Step 3 Home care initial assessment consultations that occur while the patient is still a hospital inpatient will be reimbursed in addition to the calculated inpatient IR- DRG reimbursement Step 4 The effective date for claims for reimbursement for home healthcare services is from January 2010. Following the effective date of 1st of Jan 2010, only authorized licensed providers will be eligible to submit claims to health insurance companies. Medical Billing: HAAD-approved Codes for Homecare Health Services (No. 99401-99420) http://www.haad.ae/haad/linkclick.aspx?fileticket=ccsl7hsjxls%3d&tabid=819 HAAD-approved Codes for Weqaya Screening (CVD Risk Factors) and Follow up Clinical Services (for further diagnosis, management and treatment of CVD) http://www.haad.ae/haad/linkclick.aspx?fileticket=eeeexkafhb8%3d&tabid=8 20 Page 25 of 25