Targeting frail elderly patients at high risk of preventable healthcare utilization, and providing them with telephonic case management support at two critical transitions — after they’ve been admitted to the hospital, and after they’ve been discharged from home visits — can reduce readmissions and improve patient satisfaction and care, say two key members of the Fallon Community Health Plan (FCHP) case management team, Susan Legacy, RN, senior manager of case management, and Pat Zinkus, RN, director of case management.
Our program strategies have evolved with time. When we first started the program, it was a rule that everybody would get a monthly home visit. Now that we have been doing this for a little while, we changed that philosophy. Some people need visits more frequently, while some need them less often. The program support coordinator looks at the various medical records and makes sure that we weren’t planning a visit on top of a primary care office visit or a specialist visit.
We also have after-hour visits. Through our contract with the VNA, they offer a 24-hour line. We have Home Run patients who call and access this line if they are not feeling well, or if there is a problem. A skilled nurse will do a home visit if necessary and speak with the PCP to discuss the best route of care. This has been very successful in avoiding ER visits after hours and on the weekends.
We also transition people to telephonic case management when we feel they are ready to come off of home visits. However, we don’t want to leave them high and dry, so they have a telephone contact person for the next three months. If someone starts failing again, this allows us to revamp that plan and put them back in the program for home visits.
Editor’s Note: These strategies were initially shared during a 2011 presentation on reducing readmissions.
Source: Guide to Home Visits for the Medically Complex
Guide to Home Visits for the Medically Complex examines the industry’s growing use of home visits for patients at high risk of readmission, presenting home-based initiatives from eight healthcare innovators that are helping to elevate the level of care and patient satisfaction while reducing 30-day readmissions for the medically complex and recently discharged.