Phone calls aim to keep patients out of hospital
Phone calls aim to keep patients out of hospital
Agency works to reduce readmissions
When patients who have a high risk of rehospitalization are discharged from Bayada Home Health Care's home health services, the Mooretown, NJ, home health company calls them monthly for the next year to find out how they are feeling and whether they need assistance or additional services that will help them avoid another hospital admission.
"We are starting to partner with hospitals and physician practices in accountable care organizations as reimbursement models start moving in that direction," says Eric Thul, MBA, division director with Bayada's home health practice. "Making sure patients remain safe at home and out of the hospital is an important part of community-based care. We aren't being compensated for this program but we feel it's the right thing to do."
Before beginning the Bayada Touch pilot project, the organization partnered with Lehigh University to study readmissions and developed a model that predicts the patients most likely to be rehospitalized. The pilot — begun in mid-2011 — was so successful that the organization is setting up a centralized office that will provide service to all 61 branch offices across the country. The centralized office is expected to be open this summer.
The home health organization has trained non-clinical staff to call patients and follow a script that asks them a set of questions based on their condition. "We trained them on how to approach the patients and what steps to take based on the answers they get," Thul says.
The program is overseen by a registered nurse who is available in case the patient is experiencing an exacerbation in their condition. If patients report having problems, the staff call their primary care physicians, who contact the local Bayada office and coordinate care with the local nurses. Depending on the patient's condition, the physician may decide to send out a home health nurse, to have the patient come in for an office visit, or to adjust the medication.
The callers build a relationship with patients over time and learn the best way to approach them. "Many patients say they look forward to the call every month because it gives them an opportunity to share their concerns and ask questions," he says.
The program has resulted in enhanced patient satisfaction and has provided information to the organization about how patients feel about their episode of care, Thul says. "We also can provide feedback to our employees, which has increased employee satisfaction," he adds.
The home health organization also is piloting a virtual care management program in which care monitors call patients who are at high risk for hospitalization in between the home visits from the Bayada home care nurse. The care managers conduct an assessment over the phone and document it in the electronic medical record, which is available to other staff caring for the patient.
"This program has shown good results in reducing hospitalization rates, but it's an expensive intervention since it adds another clinician to the episode of care. We're analyzing the results to determine if this is the best use of resources to drive down hospitalization," he says.
When patients who have a high risk of rehospitalization are discharged from Bayada Home Health Care's home health services, the Mooretown, NJ, home health company calls them monthly for the next year to find out how they are feeling and whether they need assistance or additional services that will help them avoid another hospital admission.Subscribe Now for Access
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