Program aims for early interventions

Home visits keep elderly away from the hospital

To help frail Medicare Advantage members with multiple medical problems live independently at home, Independent Health Association in Buffalo, NY, works with Family Choice, a care management provider, to arrange home visits. During visits, they educate members about their healthcare conditions and treatment options, discuss medication, and arrange for needed services.

Participants in the Care Partners for Frail Elders program are the frailest of the frail and tend to be among the highest utilizers of healthcare resources, says Kathleen Mylotte, MD, director for quality and disease management at Independent Health Association. "It's hard to get a good comparison group, but the trends seem to indicate a slight reduction in emergency department and hospital visits. This program is not a money-maker, but it has not proven to be a cost burden to the plan," Mylotte says.

The service, begun in 2008, is provided at no cost to the patient and is open-ended. The nurse or social worker will visit the patient as often as needed and for as long as needed. The staff are available 24 hours a day, seven days a week and can make a home visit at a moment's notice. "We have found extra value in this in-depth case management program." Mylotte says.

Most members in the program are referred by health plan case managers, health coaches, and community physicians, reports Jo Ann Calandra, RN, BSN, BCM, clinical manager for Medicare at Independent Health. "When we started the program, we used a predictive modeling tool to identify participants. This wasn't as helpful as having clinicians refer patients, either following a hospitalization or if they knew from working with the member that the caregiver was overwhelmed or the member was not thriving at home."

Suzanne Ruiz, RN, BSN, director of the Care Partners program, says that when members are referred to the program, a nurse or social worker from the Care Partners program contacts the member and talks to the family member if possible, and sets an appointment to visit the patient in the home. During the visit, the nurse conducts a thorough assessment — looking at psychological issues, safety, the home situation, and medication as well as the member's medical condition.

"We want to keep members as functional as possible in the setting in which they live with an increased quality of life, even though many of them have lost a lot of independence. The nurses, social workers, and other staff at Independent Health work to identify resources that will allow members to live at home as long as they possibly can," Ruiz says.

As long as a member is in the program, his or her care is coordinated by one case manager and one social worker, unless there is a dire emergency. "If you have been seeing somebody for many months, you can tell in a few seconds if something is wrong. "The continuity in providers helps with building relationships as we work with members and talk about advance care planning," she adds.

During the regular visits, the nurses can spot exacerbations, such as ankle edema and increased problems with minor exertion among heart failure patients. They contact the physician and either get orders to make medication changes or get the patient a same-day or next-day appointment. "This helps get the patient's condition stabilized and an emergency department visit avoided," Ruiz says.

If a member is not feeling well, a nurse is available 24-7 to troubleshoot over the telephone or make a home visit.

Mylotte adds that the nurse can identify life changes that could become major changes and intervene to prevent a hospitalization. For instance, if a member has a history of cardiopulmonary disease and tells the nurse he's feeling short of breath, the nurse can visit, assess the member, and notify the physician about changes in the member's condition. In many cases, the physician can intervene over the telephone or the nurse can facilitate a same-day physician appointment. "By providing earlier interventions, we can prevent patients from experiencing a medical crisis and being hospitalized," Mylotte says.

Care Partners does more than just provide medical care, Mylotte says. "We are trying to keep the member stable and help elderly people who are struggling to stay at home," she says. The nurses and social workers can arrange services such as Meals on Wheels, counsel patients and families on advance care planning, and help with placement for people who no longer can live independently.

All the staff members are in the field on a daily basis and see patients a minimum of once a month. Many see members more frequently and follow them by telephone between visits. "They have a small enough caseload so they can see patients as often as needed," Ruiz says.

When members who are at risk for readmission within 30 days are discharged from the hospital, they are enrolled in the Care Transitions program, which provides in-home visits, medication reconciliation, and education. A nurse visits appropriate patients in their homes within 72 hours of discharge and conducts an in-depth medication reconciliation, reviewing pre-hospital and post-hospital medications. If necessary, the nurse refers patients to a pharmacist for medication counseling. The nurse then follows up with the patients by telephone once a week for four weeks at a time that is convenient for the patient.

Ruiz adds that when a patient in the Care Partners program is hospitalized, the Care Partners nurse waits to visit the patient until the Care Transitions program is completed. The Care Partners team continues to pull together all the resources the patient needs to live at home while the Care Transitions nurse is looking at the medical piece and keeping the patient medically stable, she adds. "We want to avoid confusing members by getting too many people involved in the care," Ruiz says.