In-home visits reduce utilization for elderly

Program generates 195% ROI

A program that sends geriatricians and nurse practitioners into the homes of high risk, frail elderly patients has resulted in a 195% return on investment (ROI) for Fallon Community Health Plan in Worcester, MA.

The Home Run Program began in 2009 after the health plan and Fallon Clinic looked for ways to reduce healthcare utilization for Medicare Advantage members.

"The health plan and the clinic share risk for the care of these patients," says Patricia Zinkus, RN, CCM, director of case management. "We focused on the rising medical costs and the increase in the aging population."

Participants in the program might have multiple chronic conditions, including depression and other issues that put them at risk for complications and hospitalizations. Many of the members who are in the program have difficulty getting to their primary care physician regularly or have sought care in the emergency department when acute symptoms have occurred.

"We know that a small percentage of members are responsible for the majority of healthcare costs," Zinkus says. "Our goal is to improve the functional status and quality of life for frail, homebound, or those members with chronic progressive conditions in our Medicare Advantage population and to reduce preventable hospital admissions, readmissions, and emergency room visits."

Members in the program receive monthly in-home visits from a nurse practitioner who assesses their needs; helps them follow their care plan; and arranges for needed healthcare, equipment, and services. A geriatrician from Fallon Clinic visits the members periodically and when the nurse practitioner recommends it.

The health plan used a predictive modeling program to identify Medicare Advantage members at highest risk for healthcare utilization or hospital admissions. The target of the program is 150 members. Susan Legacy, RN, senior manager, case management says "It vacillates as some members transition into hospice or other programs. We try to keep it close to 150. "We used a predictive modeling tool after initially utilizing claims data. Because of the lag between the time the members use the services and the time we receive the claim, we missed opportunities to make a difference."

The clinical staff of the Home Run Program reviewed the files of members identified by predictive modeling and referrals from various providers to determine if there were any common denominators that interventions could address. They determined that most of the people identified had experienced a significant functional decline as the result of a fall or an illness. Some had a limited ability to participate in activities of daily living and were not able to get out of the house and socialize at their previous level of function, Legacy says.

The health plan has a contract with a local visiting nurse agency that supplies the nurse practitioners who make the home visits, Zinkus says. "This program does not take the place of the patient's primary care physician," she says. "The health plan, the nurse practitioner, and the geriatrician at the clinic all work in collaboration with the primary care physician."

When a member is identified for the program, the health plan's program support coordinator refers the member to the clinic's geriatrician, who reviews the medical record and determines if the member meets criteria. A letter is sent to eligible members explaining the program and outlining the benefits.

The support coordinator follows up and schedules an appointment for the nurse practitioner to visit the member in the home and conduct a comprehensive assessment. "The nurse practitioner is able to see the home environment and can determine if patients understand their medication regimen or if they need additional teaching," Zinkus says. "They can see safety issues in the home or anything else that can lead to an adverse event."

For example, the nurse practitioner can determine if patients with heart failure have scales to check their weight every day and if their pantry and refrigerator are stocked with high sodium foods. They can help patients make appointments with their primary care provider, arrange for additional home care services, or set up medication reminder systems if needed.

After the initial visit, depending on the needs of the member, the nurse practitioner makes monthly or bi-monthly follow-up visits. The nurses call in a Fallon geriatrician for a home visit when they think it's warranted by the patient's condition. Program participants can call the Home Run Program or the after-hours line at any time for assistance.

As an adjunct to the home visits, the health plan developed the Home Run Club, a monthly event for participants in the Home Run Program. The events are at Summit Elder Care, a senior center where the health plan operates the PACE (Program for All-Inclusive Care for the Elderly). The health plan arranges for a speaker, refreshments, and fun activities, and it provides transportation for members who need it. Zinkus says, "This is a way for the seniors to get out of the house and interact with peers," she says. "We feel that the socialization piece of the program is crucial to its success."

A social worker from Fallon Community Health Plan runs the program, and it's often attended by members of the health plan's case team. Often the members will ask a question about their health, and this question gives the staff an opportunity to educate the members or suggest that they call their doctors.

Patients may remain in the program until they experience a major life change such as moving into a skilled nursing facility or a hospice, or until they receive care from PACE. Patients whose condition stabilizes to the point that they no longer need home visits are transitioned to telephonic case management. They receive regular outreach calls from the health plan's case managers for at least three months.

"One of the other successes of the program is that we have been able to help people transition to the appropriate level of care," Zinkus says. 'If the members really need hospice care or the nurse practitioner determines that they can't live safely at home, the geriatrician can visit the home and sit down with the family and discuss alternative means of care."