Improving outcomes and lowering costs by applying advanced models of in-home care

THE VCU TRANSITIONAL CARE EXPERIENCE

The VCU Medical Center implemented a Naylor-model hospital-based transitional care program (TCP) 12 years ago that has served more than 500 patients. Targeted patients have histories similar to those observed by Naylor et al⁷: multiple hospitalizations, prolonged inpatient stays, many comorbidities and medications, complex care plans, and poor social support. Referrals come from physician teams, care coordinators, nurses, and social workers. The electronic medical record (EMR) has triggers for referrals.

Transitional care NPs meet patients in the hospital to ensure the appropriateness of their referral, introduce the program, and verify information. As shown in the Naylor model and later in the Coleman model,⁶ inpatient contact creates rapport with the patient and with family caregivers.

The first home visit is made on a weekday within 24 to 72 hours of discharge. At this initial visit, which takes a considerable amount of time, we attempt to reconcile medications, clarify social needs and resources, conduct physical assessments, modify medical regimens, educate the patient and his or her caregivers, and run diagnostic laboratory tests as needed. What we see in the home on this first visit often does not correspond with what was previously reported by hospital-based clinicians. For example, we have found that many patients are not taking medications as prescribed.

Typically, we visit homes weekly for 4 to 8 weeks. Some patients remain in transitional care for longer periods due to medical and social reasons. The NPs maintain close contact with home health agency staff via mobile phones. In some cases we conduct joint visits with home health agency staff in order to facilitate adjustments to medical care plans. Regular communication with primary care providers via the EMR, fax, and phone helps close the follow-up gap. The NP’s ability to observe the home setting, identify barriers to medical compliance (including literacy), and address social issues offers a clearer picture to care providers and fosters better outcomes. As patients improve and become more mobile, they return to the care of the primary provider.

Positive results with some limitations

We collected data between 2003 and 2006 on patients enrolled in the VCU Medical Center TCP. Our demographic results were similar to those reported by Naylor et al.⁷ Prevalent diseases included heart failure (HF), coronary artery disease, diabetes, and chronic obstructive pulmonary disease (COPD). The mean age was 71 years. The patient population was 63% female and 77% African American. About 73% of patients returned to the care of their primary physicians, 13% enrolled in the VCU House Calls program, 12% died, and 3% were admitted to nursing homes.¹⁰

A comparison of utilization data for 199 patients 6 months before and after their enrollment in the TCP over a period of 4 years showed decreased use of hospital resources—ie, fewer inpatient days, shorter lengths of stay, and fewer intensive care unit days— after enrollment. Aggregate cost after TCP enrollment reduction was $2,251,344¹⁰ which is 38% less than the 6-month pre-enrollment baseline (Table 2). Regression to the mean played a role, but most patients had a sustained high-use pattern for 6 months before enrollment. The high rate of consumption of health care resources dropped quickly following implementation of the TCP and stayed down for many months.

We largely concur with Naylor’s description of transitional care implementation.¹¹ However, we have found that many transitional care patients are unable return to the clinic after 2 months, as suggested by Naylor. In our system, these patients default to our House Calls program for continuing care. Thus, in our estimation, transitional care is an important but incomplete response to population-based health needs. Supporting this conclusion is the Congressional Budget Office report, which states that among high-cost Medicare patients in an index year (2001), those who lived for 5 years were high-cost patients on a month-by-month basis in 22 of the next 60 months, reflecting chronic illness and cyclical service use patterns.¹²

Extension of the TCP to outpatients

Because of the favorable effect observed in the hospital-based TCP, we created a role for transitional care in our outpatient geriatric practice. Transitional care NPs from the clinic practice have the option of making home visits in a variety of scenarios. In the least serious cases a single “diagnostic” home visit provides invaluable insight. For example, we evaluate support systems and compliance with medication instructions and put systems in place to help patients maintain independence and safety at home, including nutrition and fall prevention programs. Patients with poor social support benefit especially from home visits.

We find that high-risk patients recently discharged from facilities, including those outside our health system, benefit from NP visits. When a high-risk clinic patient is hospitalized, we maintain a connection with the inpatient team, follow the patient’s progress, and assist with discharge planning. Based on our relationship with the patient prior to admission, we are able to anticipate problems and to address them promptly after discharge. The NP functions as the “hub of the wheel” to coordinate the multidisciplinary plan among primary care providers; specialists; and support services such as home health, social work, and physical therapy.

We also initiate periodic NP home visits as chronic diseases progress and as clinic patients become increasingly frail. Interim visits are made to monitor the medical plan and perform follow-up blood testing. Once patients are no longer able to use the office practice, they transition into the House Calls program.

HOSPITAL AT HOME

The ultimate in substitutive, intensive home care occurs when one replaces acute care hospital admission with care delivered entirely at home. Robust research has shown comparable or better clinical outcomes with fewer complications and lower costs when home care is applied to common conditions such as pneumonia, COPD, cellulitis, and HF.^13,14 Rapidly advancing technology now supports increasingly sophisticated care at home. For example, with low molecular weight heparin, the care of deep vein thrombosis and stable pulmonary embolism—which always required inpatient care 25 years ago—can now be delivered entirely at home in many cases. Soon, these conditions may be managed solely with oral medication.^15,16 The range of conditions that are now being managed at home is extensive, and the transformation of health care by portable technology is just beginning.¹⁷

LONGITUDINAL IN-HOME PRIMARY CARE

In the United States, patients who are immobile and cannot easily access office-based care often suffer with suboptimal mobile primary care. This represents a major limitation in care access for these patients. There is good evidence that longitudinal medical care, primarily delivered at home for periods lasting many months to several years, is effective and that it makes clinical sense. In the home, providers can accurately assess the patient’s living situation, engender trust, and respond in a timely manner when a patient’s condition changes. The Geriatric Resources for Assessment and Care of Elders (GRACE) program and the Veterans Affairs (VA) home-based primary care model are two examples of the benefits of longitudinal in-home care.

In the GRACE model, patients receive comprehensive in-home assessment by NPs with quarterly follow-up, and recommendations are given to primary care providers. The program’s clinical trial demonstrated markedly improved treatment of a variety of common geriatric ailments and reduced costs in a high-risk subset of patients.¹⁸ GRACE was not designed for urgent care but the approach was linked to lower costs in high-risk cases, likely due to better care and improved access.

The VA home-based primary care model has grown rapidly in the past decade, now operating at more than 200 medical centers, each with a full interprofessional team. House calls by physicians and NPs are part of the model, although the frequency varies across sites. Every team includes actively engaged physicians. Medicoeconomic evaluation based on tens of thousands of patient-years has shown an overall reduction in health care costs of 15% to 25% compared with historical values and prospectively modeled dollars.^19,20 Home-based primary care teams are emerging across the United States at many academic centers and in the private sector.

To fund comprehensive longitudinal home care services for patients with complex health problems, the Independence at Home²¹ demonstration program was created under section 3024 of the Patient Protection and Affordable Care Act, using robust gain-sharing from demonstrated cost savings to reward house call teams. This multisite 3-year program started in June 2012. Rapid growth of this model is likely as private insurers have also taken an active interest in mobile medical care designs, using a variety of reward structures.

TELEMEDICINE

A debate continues over the use of communication technology in home care. It seems intuitive that “virtual visits” would be more efficient than clinicians visiting patients at home. Yet, the challenges of improving care by telemedicine alone are underestimated. For example, a recent large randomized trial, in which 33 cardiology practice sites provided at-home postdis-charge telemonitoring for HF patients, demonstrated no difference in clinical outcomes compared with patients monitored in the hospital or clinic.²²

Proponents of telemedicine cite integrated models where data are managed proactively by a physician-led team that is engaged in care. This view seems valid, but other than anecdotal reports from integrated health systems, the published evidence of reduced costs is sparse. Some combination of in-person care and telemedicine is likely to be the optimal design and will emerge in coming years.