One of the great benefits of being involved in a three-year national demonstration project like Independence at Home (IAH) is that it offers lessons every day on how to serve our patient population more effectively and efficiently.
Significant innovations are being implemented and piloted because of what was learned that initial year. Perhaps the most important lesson to emerge from our participation is the importance of advocating for patients throughout the many phases of their care, be it emergency services, hospitalizations or follow up care. We now know that this continuum of care should and can be expanded to include our entire patient population.
A second major takeaway deals with risk assessment. The demonstration project helped us to understand the need to create a risk assessment tool for all IAH patients to gauge the likelihood that they would need additional medical or emergency services over the course of their care. We believe this tool will allow clinicians and the transitions of care team to be more proactive in treating these high-risk patients.
“After reviewing the data from the first year of the demonstration, it was clear that the transition team had a great influence on reducing emergency department visits as well 30-day hospital readmissions,” stated Mary Sayre, RN, our primary care program director,. “Going into the second year we changed our practice and hired two more nurses (for a total of three) and began to utilize social workers as members of the transitions of care team. They are working with all our patients now, not just those involved in the IAH demonstration. Along with the primary care providers, they are identifying patients with complex medical issues and psychosocial needs, addressing whatever condition or factor might push them into the hospital.”
The transitions of care team interacts with Housecall Providers patients as they move in and out of the hospital. The team confirms coordination of care, assists with care conferences and end-of- life discussions, and provides follow-up in home visits to ensure medication reconciliations in coordination with the primary care providers.
The first quarter that the team was fully implemented, Housecall Providers saw a decrease in 30-day hospital re-admission rates from 15.1 to 8.1 percent. “We have approximately 88 patients visiting emergency services each month and from that about 50 patients enter the hospital. What the clinicians and the transition team were able to accomplish that first quarter was really beyond our expectation,” Sayre said.
The transitions of care team will now have a valuable tool to assist them in identifying potentially high-risk patients. Most recently, the team reviewed and “risk scored” all IAH patients to indicate those patients who will need more oversight. “Housecall Providers’ highly trained geriatric clinicians have led the way for the success of the transition team,” Sayre said. “These innovations are steps we are taking to continue to meet the complex needs of the homebound while enhancing our commitment to excellent patient-centered care.”
