nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 1

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1 Optimizing Transitions in Care: House Calls for Vulnerable Elderly Patients Kristine Todd DNP, FNP-BC, RN-BC 2 MERCY HEALTH SAINT MARY S A premier health care system in west Michigan Servicing residents of 15 counties: Teaching hospital with 377 licensed beds 240 acute care, 122 psychiatric, and 15 NICU Comprehensive cancer center and neuroscience programs; kidney transplant center of excellence Annually: 22,000+ inpatient admissions; ~20,000+ surgeries; 80,000+ emergency visits; 30,000+ urgent care visits, 900,000+ outpatient visits 3 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 1

2 Trinity Health One of the largest Catholic health system in the United States More than 89,000 full-time equivalent employees Ministry Organizations/ Regional Health Ministries encompassing: 86 hospitals 70 long-term care facilities 44 home health and hospice programs Located in 21states across the nation 4 Objectives Describe the risk factors associated with hospitalization and readmission Recognize elderly patients who could benefit from a bridging house call service Identify essential elements to the success of a bridging house call program 5 Aging Population Implications The complexity of care for vulnerable elders expand across the entire healthcare continuum Nearly 18% of Medicare patients are readmitted to the hospital within 30 days of discharge Readmission rates for patients with multiple chronic conditions are as high as 25% Within 90 days of discharge, as many as 30% of Medicare recipients will be readmitted to the hospital 6 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 2

3 Aging Population Implications Older adults that live alone are twice as likely to be readmitted if they don t have supportive community services To succeed in today s challenging healthcare environment, healthcare systems must implement innovative processes to improve care for elders who are at risk for re-hospitalization Bridging interventions such as with physician continuity from the inpatient setting to the outpatient setting has potential to improve patient outcomes 7 Bridging House Call Service Originally named THRIVE (Treating at Home to Retain Independence for Vulnerable Elders) Morphed into the ACCP (Advanced Care Coordination Program) Goal is to return the patient to PCP within 90 days unless plan of care changes (Hospice) 8 Patient MOST Likely to Benefit Older adults With multiple chronic illnesses that have been hospitalized with an acute illness Being discharged to home with decreased functional capacity Discharged home with transportation issues causing them to struggle with getting to PCP for follow up care With cognitive impairment making it difficult to navigate the healthcare system 9 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 3

4 Patient LEAST likely to Benefit Older patients Whose primary problem is psychiatric in nature With no stable home setting or support system Pattern of poor health maintenance or adherence to plan of care Where it is difficult to make phone contact with the patient 10 Predictors of Benefit of a Coordinated Approach >1 visit to the Emergency Room or Hospital in last 6 months Many care settings (hospital, SNF, home healthcare, sub-specialty clinics) At least one severe chronic illness (heart failure, COPD) Functional Impairment (difficulty ambulating, cognitive, vision, or hearing impairment) A pattern of inability to access their PCP (no show or cancelling appointments) 11 Referral Base Attending or consulted physician at the hospital Michigan Health Connect Case management Clinical Nurse Leaders Complex Care Team Palliative Care Team 12 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 4

5 Team Members Geriatrician Palliative Care Physician Nurse Practitioners Social Worker Program Manager Home Health (lab services,etc.) 13 Process for Bridging Service After referral is made the geriatrician will see the patient while in the hospital The first day after hospitalization the home health nurse will see the patient The following day the geriatrician or NP will do an initial evaluation of the patient (H&P, med rec) Within 3 days of intake visit the PCP office is contacted by the geriatrician to discuss assessment of care needs Within one week of intake visit a second visit is offered and at that point the bridging service becomes the firstcall for all patient needs (labs, refills, etc.) 14 Process for Bridging Service Once the patient is ready to be transitioned back to the PCP there is an explicit handoff of first-call duty back to the PCP Documentation occurs in NEXTGEN which PCP have access to 15 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 5

6 82 patients sampled, 63% reduction in visits (ED, OBS, INPAT) 16 Overall Hospital Re-hospitalization Rates COPD Pneumonia Myocardial Infarction Heart Failure 17 Overall hospital re-admission rates of COPD patients 18 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 6

7 Overall hospital re-admission rates of pneumonia patients 19 Overall hospital re-admission rates of MI patients 20 Overall hospital re-admission rates of HF patients 21 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 7

8 References Beck, R., Arizmendi, C., Purnell, B., & Fultz, C. (2009). House calls for seniors: Building and sustaining a model of care for homebound seniors. Journal of American Geriatric Society, 57(6), Physician visits after hospital discharge: Implications for reducing readmissions NIHCR research brief No. 6 (accessed January 23, 2015) 22 THANK YOU!!!! QUESTIONS??? nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 8