Local Problem: Placer and Sacramento Counties in Northern California has a growing older adult population living alone, thus, may need assistance in times of transitions from acute or SNF care back to their domicile. In the Sacramento region, 30-day, all-cause hospital readmission rate was 17% versus California’s rate of 18.5%. Patients discharged from a hospital directly to home had 41.2% readmitted, of those who did not see their primary care provider (PCP). Almost 60% (58.8%) of patients who were readmitted to a hospital did not have a 30-day follow-up visit from a PCP; 36.2% returned within a week of discharge.
Purpose: This quality improvement pilot project considered medical house call as a component of Transitional Care Management (TCM) in reducing unplanned 30-day readmission to the hospital. As a secondary outcome, the project explored point of care concerns encountered during the medical house call visit conducted by a nurse practitioner (NP).
Methods: The 4-month project followed Medicare beneficiaries who were discharged from skilled nursing facilities (SNFs) to home. Unplanned 30-day readmission to the hospital was measured and correlated to point of care conditions found during the medical house call visit such as the number of days it took to see the patient; the common distribution of L.A.C.E. scores; the number of medications (polypharmacy) before the visit and after the visit (medication reconciled); the number of visits requiring prescriptions; the kind and number of co-morbidities which included HF, CKD, COPD, Dementia, DM, and HTN; and the number of patients who had no PCP at time of visit, or if they did, the number of days follow up visit was available and scheduled.
Intervention: The addition of medical house call visit to TCM performed by a provider with prescriptive authority, the NP.
Results: A total of 145 patients’ outcomes were analyzed which showed that Heart Failure (HF) was a predictor for unplanned 30-day hospital readmission. HF patients were seen to be five times more likely to be readmitted. Confounding factor was that majority of patients were high risks for readmission based on L.A.C.E. scores, almost half requiring medication prescription at the time of visit, and more than half took more than 14 days to see their PCP after discharge. The visit addressed polypharmacy significantly, with patients having 17 medications before the visit reduced to 11 after medication reconciliation.
Conclusion: This project has shown that older adult patients discharged from a higher level of care can benefit from Transitional Care Management through medical house call by a NP within 14 days after discharge. The visit significantly reduces polypharmacy, provides a way to get prescription of medications that would otherwise be obtainable from the PCP in 14 days or more, and addresses high readmission risks.
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