Assessing Effectiveness of a Home Visit Program

Tuesday, March 22nd, 2011
This post was written by Jessica Fornarotto

Pam Aldridge, manager of care management at Durham Regional Hospital, explains how her organization measures the effectiveness of its outpatient care program.

To assess the effectiveness of our Care Partners program, we had individual balanced scorecards developed for each patient utilizing the balanced scorecard format. The metrics were developed based on historical cost data; targets were developed and discussed with Care Partners and the oversight committee for our pilot patients.

Patients who demonstrated compliance with the program and had no unplanned admissions during Phase One were eligible and invited to graduate into a less intensive Phase Two. These patients in Phase Two continued to be in contact with their case managers. If they have no unplanned readmissions and wish to continue with the program, they will graduate to a Phase Three, which represents a period of maintenance and self-direction for the patients. Ultimately, our program strives to empower patients to effectively manage their own healthcare needs.

We created the Care Partners Pathway, which marks a successful transition from Phase One to Phase Two. The patients who moved among the phases had continued compliance with their established outpatient care program, successfully engaged in Phase Two for six months, had no unplanned readmissions and had fewer than two ED visits in a three-month period. In Phase Two, the patients received one contact per month and one face-to-face visit within three months.

If the patients demonstrated continuous compliance with the established outpatient care programs, had no unplanned readmissions and had fewer than two ED visits in another three-month period, they moved to Phase Three. In Phase Three, they had one contact with their case manager per quarter and then graduated from the Care Partners program. At any time during these phases, the patients could call their case manager for advisement, to talk to them and to get information.

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