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Post-discharge visits reduce rehospitalizations
MD or nurse practitioner visit patients' homes
Members who received a post-discharge visit from a physician or a nurse practitioner experienced 20% to 30% fewer readmissions than patients who received only telephonic care management during a pilot project by XLHealth, a Baltimore-based provider of health plan solutions for Medicare beneficiaries with special needs, according to John Mach, MD, XLHealth's chief medical officer.
Now that the pilot is complete, the health plan is working with its contracted community nurse practitioners and physicians to expand the program to the entire service area and will continue to focus on patients at highest risk, he says.
The program aims to reduce unnecessary and costly readmissions among the high-risk members of Care Improvement Plus, XLHealth's Medicare Advantage plan, says Mach.
"Far too many seniors with chronic conditions have repeat hospitalizations, causing an out-of-control revolving door. As a health plan that focuses on these people, we are stepping up our efforts to make sure our members are getting the follow-up care they need to break this cycle," he adds.
The initiative follows the success of XLHealth's HouseCalls program for members with chronic illnesses. The health plan's network of 240 doctors and nurse practitioners completed more than 80,000 HouseCalls visits to at-risk members last year and expects to complete more than 6,000 post-discharge visits by the end of 2011, Mach says.
"This program is a natural extension of our HouseCalls program. It has been so successful, we were looking at ways to utilize the capacity of the nurse practitioners and physicians with whom we contract. The natural place was the transitional care issue. This is one of the many ways we are expanding our ability to support members in their homes at times when they most need our help," Mach adds.
The health plan experimented with using home health nurses during the pilot project but determined that the physicians and nurse practitioners were more effective in assessing members who have complex medical needs.
Since the health plan already contracted with doctors and nurse practitioners for its HouseCalls program, the decision was made to use them for the post-discharge visits, Mach says.
"The nurse practitioners and physicians were able to get to the patients' homes in a more timely way, completed more visits, and had slightly better results. The difference in cost of using the more highly trained clinicians was not a significant deterrent. All of these patients need specialized care, and medication is a critical issue," he says.
The community-based clinicians who visit the patients in their home work closely with Care Improvement Plus' care management team and the patients' primary care physicians to ensure that the patients get everything they need to stay healthy at home and avoid emergency department visits or readmissions.
About 75% of the health plan's members live in rural areas and 30% do not have a medical home, Mach pointed out.
"The program is particularly beneficial for members who are in locations that may not have robust transition of care processes. The doctors and nurses step in and provide that coordinated post-discharge education and care," he says.
Members in the pilot project were at highest risk and were in selected service areas. Half were randomly chosen to receive the home visits. The remainder were assigned a telephonic case manager.
When members who are stratified as high risk are hospitalized, the health plan utilization nurses notify the community-based physician or nurse practitioner so he or she can schedule a visit within a few days after the patient gets home.
"People who are in our low-risk categories often are hospitalized with a stroke or a new condition. Our utilization nurses are trained to identify people who change risk categories and assign them to a care manager and arrange a visit from a physician or nurse practitioner," he adds.
When they visit a member's home, the clinicians fill out a structured interview form, which has room for additional information. They send the information back to the care manager, who enters it into the health plan's care management system where it is available throughout the health plan to anyone who has contact with the member.
"The doctors and nurses act as our eyes and ears in the home. They take a close look at the medicine bottles, pick up on environmental issues or family issues, and take a good look at the member to see all of his or her conditions and capabilities," Mach says.
They make sure that the patients have filled their prescriptions, that home care visits have been scheduled, and that the necessary medical equipment has been delivered.
They alert the plan's care managers if equipment is missing or the patient hasn't heard from the home care agency. Any medication issues are identified and brought to the attention of pharmacists, who can conduct in-depth medication counseling sessions with members as well as reach out to the members' pharmacists and providers on recommended therapy adjustments, Mach adds.
The doctors and nurse practitioners make sure that the members understand their post-discharge plans, that they have a follow-up appointment with a primary care provider, and that they understand their medication regimen.
"The health care system is fragmented, and often patients receive medication changes while they are in the hospital. The discharge medications don't always correlate with what is in their home and patients are confused about which to take. There's a long list of reasons why medication becomes the central focus. The value of using nurse practitioners and doctors in the program is that they are very astute in terms of medication management," Mach says.
The clinicians inform the care manager about any long-term issues the patient may face.
Occasionally, based on the fragility of members, the care manager will schedule another visit by nurse practitioner or communicate with the member's primary care physician.
"We take the information we have and get it back to the primary care physician, either electronically or by telephone if it's urgent," he says.
The clinicians spend about an hour at the members' homes, providing support and education, and going over the medication regimen.
"These people are still relatively sick, and it may not be the optimal time to coach them on lifestyle issues. A few weeks out, when they are more stable, the care managers will begin to work with them," he says.