Meeting the Home Care Needs of High-Risk Patients

Care transitions are a key area of focus to prevent avoidable hospital readmissions, and home care is an integral part of this work. Regions Hospital in St. Paul, part of ICSI member HealthPartners and a participating hospital in the RARE Campaign, identified one area that needed particular attention: high-risk patients who are unable to access home care services due to lack of insurance coverage, high deductibles or co-pays, or disqualification because they are not considered “homebound” by Medicare.

In late 2011, Regions partnered with HealthPartners’ Integrated Home Care on a pilot project with congestive heart failure patients to identify and intervene in issues that may contribute to readmission, such as delayed follow-up with the primary care provider, plan of treatment concerns, and self-management deficits.

Results of original pilot were promising

The project, which included at least one home visit by a registered nurse (RN) and telephone follow-up until the patient was stable and established with the primary community provider, was funded by a $1,000 grant from the Regions Foundation. Before the pilot began, three high-risk patients were identified that had experienced nine emergency department (ED) visits and eight hospitalizations. After the pilot, there was only one ED visit and no 30-day readmissions.

Second, expanded pilot also showed good results

Based on these results and input from hospitalists and care management staff, Regions Hospital received additional funding (approximately $5,000) to include all diagnoses and additional services of up to five visits by an RN, physical therapist (PT), occupational therapist or social worker, plus telephone support. This pilot ran from February through July of 2012 and served 19 patients. Many didn't speak English and had numerous co-morbidities. Eight of the patients had mental health issues, two were homeless and four had significant financial concerns.

During the second pilot, patients received 35 nursing visits, 21 PT visits, and seven social worker visits. Before the grant, there were 23 ED visits and 19 admissions from this group. Afterward, there were 18 ED visits and four admissions (but with a shorter length of stay). ED usage decreased by 28 percent. Although 21 percent of the high-risk patients were re-hospitalized within 90 days, this is below state and national rates reported by the Centers for Medicare & Medicaid Services.

Lessons learned

Project co-leaders Josh Brewster, Director of Care Management, and Denise Edgett, Manager of Integrated Home Care, believe this work offers a good reminder of the valuable perspective home care brings to preventing avoidable readmissions.

“You can’t underestimate the power of a home visit to understand the patient’s needs, especially when it comes to medication reconciliation,” Brewster noted. “What you hear from the patient may not be what you see in the home.”

Other lessons learned included:

• The team didn’t anticipate the extent of language and other cultural challenges faced by these patients, and recognized the need to better understand and address social, environmental and economic determinants of health.
• Behavioral health diagnoses (more than 40 percent) and other unmet needs played a bigger role than anticipated. Because the social workers were generalists, there was a gap in their ability to assist those with behavioral health issues or at least get them connected to the services they need.

Next steps

While the search continues for sustainable funding, in late 2012 Regions received another grant to continue this work, with the addition of interpreter services. The team is striving to connect with all the services available throughout their community, and in January 2013 expanded to Lakeview Homecare in Stillwater to better serve patients in Washington County and western Wisconsin.

“This work has really helped us articulate to case managers and others just how important home care services are, and how critical it is to get the patients the services they need, even when creative solutions are sometimes needed to pay for it,” Edgett commented. “Relatively low-cost interventions can do great things.”

For additional information, contact Josh Brewster at 651-254-3780 or Denise Edgett at 651-415-4005.