NP-Led Transitional Care Medical House Call Visits Reduce ER/Hospital Unplanned Readmissions of Homebound Seniors

Subject Population: Elderly Medicare beneficiaries who are homebound enrolled in a Nurse Practitioner (NP)-led Transitional Care Medical House Call Program receiving a medical visit in their own homes or communities within seven days of discharge from hospital or skilled nursing facility (SNF) who are under home care. 

Purpose: The purpose of this presentation is to show the results of a 90-day pilot study on the effect of a Nurse Practitioner transitional care medical house visit within seven days of discharge from the hospital of skilled nursing facility to unplanned Emergency Room (ER) visits or hospital readmissions for vulnerable homebound elderly patients in collaboration with a local home care agency. Furthermore, the pilot study was able to determine the resources needed and uncover logistical requirements for a sustainable Transitional Care Medical House Call Program.

Study Design: Using simple data collation from existing electronic health record.  The data includes visits within seven days by a Nurse Practitioner and looked at the effect of a transitional care medical house visit to unplanned Emergency Room (ER) visits or hospital readmissions for vulnerable homebound elderly patients in collaboration with a local home care agency. The pilot study was to determine if a transitional care medical house call visit reduces ER/hospital unplanned readmissions. The pilot study was also able to determine the resources needed and uncover logistical requirements for a successful Transitional Care Medical House Call Program.

Instrument: A simple analysis of cases within a 90-day period of a NP-led transitional care medical house call visits as relates to rate of ER/hospital unplanned readmissions, as the intervention. Data was obtained using the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant electronic health record (EHR).

Procedure: Signed consents were obtained prior to each visit. Data was gathered using an electronic health record. Data were extrapolated to determine if there is an indication of a reduction in unplanned readmissions as compared against Medicare benchmark. The details of each visit was also used to uncover logistical requirements for improvements to the program and for launching the program on a full-scale and wider-range basis, as well as for areas of expansion (e.g. other home care agencies, other health institutions, etc).

Results:  Between the pilot study period of September to November, 2015, 51 referrals (n=58) were made by the home care agency to Senior Care Clnic Medical House Calls for homebound (or temporatily homebound) elderly patients who are Medicare beneficiaries and who are at high risk for ER/hospital readmission (e.g. diagnoses of COPD, CHF, Diabetes, dementia, etc). Within this period, 25 patients (43%) were visited in their homes for a medical visit within seven day after discharge from hospital or SNF. Twenty-seven (33) patients referred were not seen (57%) due mainly to patient and/or family refused the visit. Out of those that were seen, one was readmitted (4%) due to rapid decline in health condition (i.e., became unresponsive) and was sent to the Emergency Room. 

In comparison with benchmark, Medicare.gov Health Compare (2013), the collaborating home care agency showed an improvement (reduction) in rates for Measure A - How often home health patients had to be admitted to the hospital, had a 13.5% benchmark rate and  Measure B - How often patients receiving home health care needed any urgent, unplanned care in the hospital emergency room – without being admitted to the hospital had a 14.2% benchmark rate. Measure A and Measure B, for the purpose of this study, were averaged resulting to a benchmark readmission rate of 13.85%. The readmission rate was reduced to 4%, during the pilot study period, for those patients who were given the intervention of a transitional care medical house call visit within seven days of dischage from hospital or SNF. There was a resultant 9.58% point reduction during this pilot study period as compared against benchmark.

Data obtained from pilot study period of October to November 2015 based on electronic health record from Senior Care Clinic Medical House Calls practice.

Demographics – age (>65yo), gender (male and female), living in Sacramento/Placer counties (rural/urban) of California, USA.

Population Need – readmissions to the ER/hospital within 30 days of discharge. Chronic care management of conditions such as DM, CHF, CKD/Dialysis, COPD.

Health, Behaviors, and Environmental Determinants – diagnoses, severity of illness, behavior, discharge instructions, availability and quality of post-discharge care, planned/follow-up surgery/readmission (excluded).

Factors that Predispose, Reinforce or Enable Behaviors – medication reconciliation, scores for hospitalization risk, fall risk, depression risk, nutritional risk, adequacy of discharge patient education, and post-discharge continuity checks.

Interventions – homebound elderly population over 65 years old under home care, transitional care medical house call visit within seven days of discharge from hospital or skilled nursing facility.

Complementary intervention – home health or home care agency providing nursing visits and oversight.

Outcomes – reduction in readmissions by 9.58% points versus benchmark, visits were reimbursed by Medicare (CPT code 99495/99496) showing financial viability and sustainability of the program. The program was supported by home care/home health. The program involved medical, nursing and community collaboration.