Nurse visits result in fewer readmissions
Nurse visits result in fewer readmissions
Project targets high-risk patients
Aetna's pilot program sending advanced practice nurses into the home of at-risk Medicare patients within seven days of hospital discharge resulted in a 20% decrease in hospital readmissions, over and above the 23% readmission reductions already achieved by the health plan's case management program for Medicare Advantage patients.
The pilot program demonstrated a cost saving of $175,000, or $439 per member per month.
"The other benefit to the program is that patients were able to stay healthier and experience a greater quality of life. Our goal is to develop programs that demonstrate impact on the intersection of quality and costs. The way to save costs is to provide better quality care for patients," says Randall Krakauer, MD, national medical director for Aetna.
For the pilot study, the health plan partnered with the University of Pennsylvania to adapt the Transitional Care Model for a population of 155 Medicare beneficiaries in the Philadelphia area. The Transitional Care Model was developed by Mary Naylor, PhD, RN, and colleagues at the University of Pennsylvania School of Nursing.
"We had a strong telephonic case management program that was identifying and managing our Medicare membership who were at-risk for readmissions or had special needs, such as coordination of end-of-life care. We conducted the pilot to see if it provided additional value to our population that already was receiving case management," he says.
For the pilot, Aetna identified a population believed to be at risk for an unsuccessful transition to the community. Criteria included dementia, depression, a previous history of avoidable readmissions, and selected clinical conditions. Some members for the program were also identified by concurrent review.
After the successful pilot, Aetna is expanding the program to communities throughout the country wherever there is a sufficient concentration of members.
The health plan contracts with advanced practice nurses living in the patients' community because they are familiar with services and community resources in that specific area.
The nurses visit the patients within the first seven days of discharge because that's when most of the problems occur, Krakauer says. During the visits, the nurses complete an assessment to determine if patients have everything needed to follow their treatment plan and arrange for whatever the patients need to live safely at home. For instance, they may arrange for home health, housekeeping services, Meals on Wheels, physical therapy visits, or nutritional consults.
They educate patients and caregivers about the patients' care plans, why it's important for the patients to take their medication and follow their treatment plans, signs and symptoms that could indicate problems, and who to call if the symptoms get worse. They make sure patients understand what medications they are to take and how to take them.
"Very often patients have medication at home and get a new prescription when they leave the hospital and don't know which to take. By being in the home, the nurses can compare the medication list that patient got upon discharge with the medication the patient is taking and communicate with the doctor to make sure the patient takes the right medication," he says.
Since Medicare patients often are vulnerable to falls and other accidents, the nurses conduct an assessment of the home to make sure the patients' living situations are safe and arrange for equipment, such as grab bars in the shower, or advise patients or family members to make changes, such as removing throw rugs.
After the initial home visit, the nurses contact patients by telephone at intervals that depend on the patients' conditions, and may visit the patients in the homes again or accompany them to doctor visits. They contact the patients' primary care physicians to let them know what is going on with the patients and to alert them to any problems.
The pilot program resulted in significant improvements in functional status, depression symptoms, self-reported health, and quality of life, as well as saving money, Krakauer says.
For more information on the Transitional Care Model, visit: www.transitionalcare.info.Aetna's pilot program sending advanced practice nurses into the home of at-risk Medicare patients within seven days of hospital discharge resulted in a 20% decrease in hospital readmissions, over and above the 23% readmission reductions already achieved by the health plan's case management program for Medicare Advantage patients.
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