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Home health link helps avoid costly hospitalizations

From the May ACP Observer, copyright © 2007 by the American College of Physicians.

By Stacey Butterfield

It was a simple case of the hiccups that made general internist Dennis Manning, FACP, appreciate well-coordinated home health care.

One of his patients, who had a history of heart failure and frequent hospital admissions, had been coming down with hiccups a few days before the classic symptoms and signs of heart failure. The patient's home health care nurse recognized a pattern and alerted Dr. Manning at one of their bi-weekly meetings in his office. The next time the hiccups began, Dr. Manning and the nurse were able to initiate treatment early and the patient was kept out of the hospital.

"Because of this astute observation and communication, we got to adjust his diuretics when he was going into this sequence of events that would have led to hospitalization," said Dr. Manning, director of quality and patient safety at the Mayo Clinic Department of Medicine in Rochester, Minn.

Dennis Manning, FACP, and a team of health care workers discuss home health care needs with a patient.


Dennis Manning, FACP, and a team of health care workers discuss home health care needs with a patient. The Mayo Clinic team involves (from left): Alisha Banken, RN, from the Department of Nursing, Erin Heeden, Social Worker, from Medical Social Services, and Deborah Beck, RN, a Discharge Planning Coordinator.



Encouraging such effective teamwork between physicians and home health providers is a goal of the 2007 Home Health Quality Improvement National Campaign. Sponsored by the CMS and conducted by state quality improvement organizations (QIOs), the campaign aims to improve the quality of home health care and reduce avoidable hospitalizations.

Currently, more than a quarter of Medicare's 2.9 million home health patients are admitted to the hospital every year, according to CMS. "We know that with better communication, better interactions, there are opportunities for reducing that rate," said David Wenner, DO, medical director of Home Health QIO Support Center.

Since January the quality improvement campaign has enrolled more than 4,000 home health agencies committed to reducing their patient hospitalization rates by a relative decrease of at least 5%.

Recognizing the patients

Internists are already treating large numbers of these patients, said Stephen L. Winbery, ACP Member and associate medical director for the Tennessee QIO. The issue is figuring out which patients are being unnecessarily hospitalized and determining how to break the cycle.

"The classic example that most physicians can identify with is a heart failure patient who is so brittle that they seem to be in the hospital all the time. I personally know many who would consume $5- or $6 million in resources every year," said Dr. Winbery.

Keeping a patient like this out of the hospital not only saves money for CMS, but makes life happier for the patient and his or her family. "That's not much of a quality of life if they're spending all of their time in a health care facility. Home health can offer them better things," Dr. Winbery said. In many of these patients, the exertion of just leaving the house can be enough to cause an exacerbation, so the stress of a hospital visit is an additional trauma, he noted.

In addition to heart failure, chronic obstructive pulmonary disease (COPD) and diabetes are two diseases that experts frequently cite as causes of avoidable hospitalizations of home health patients. Statistically, respiratory problems are the most common reason for hospitalization, followed by exacerbation of congestive heart failure, according to Home Health Interactive, an industry organization.

The campaign's broad quality improvement efforts touch many other conditions. On some level, any home health patient's care can benefit from the 12 best practice interventions included in the quality improvement project, to be released once a month online during the year-long campaign. Home health agencies receive educational tools and resources, guidelines and example success stories with each intervention.

Physician communication is one of the monthly themes and an important area where home care can be improved, said Jennifer Markley, director of the campaign for TMF Health Quality Institute, the Texas QIO.

"We're working really diligently with the home health agencies on their communication style-having a standard tool for communication, making sure that when they contact the physicians, they're prepared," she said.

Physicians can help by making themselves available to the home health providers. "The physician should make sure the agency knows they're to be contacted when any problem arises," said Abraham Delgado, FACP, an internist and medical director of TMF, based in Austin, Texas. "The expectation of the patient and the home care agency should be that the primary care provider would be available to see a patient soon after they started having an exacerbation or a new problem," he said.

Before a problem arises, physicians should let home health nurses know how they prefer to be contacted—a phone call to the office, a beeper page, fax, e-mail or even a cell phone. The protocol may vary depending on whether the communication is urgent or not, but the system should be set up in advance.

"If the agency and the physician work together to set up a process, a lot of times when there is an emergency, it's more likely that the process will go smoothly," said Ms. Markley.

The physician-home connection

Experts acknowledged that the development of a communication system can be somewhat time-consuming at the start, but pointed out that the time is often recovered later when a home health nurse takes care of a problem that would otherwise require the physician's attention.

"They may be able to be the eyes and ears for the physicians and alert them to a deteriorating patient, reducing the number of phone calls from patients and interactions with the emergency room," said Dr. Wenner.

Home health nurses can also save physicians time by prepping patients for office visits and helping them to become more involved in their own care. "We're trying to have patients come to their encounters more prepared and have some ownership over core pieces of information," said Eric Coleman, ACP Member and associate professor of medicine at the University of Colorado at Denver and Health Sciences Center.

Medication management is one area especially where information needs to be communicated accurately among physicians, patients and home care agencies, and it is one of the quality improvement campaign's 12 target areas. "Some of these patients have as many as 20 or 25 medications," said Ms. Markley. Home health providers can work with physicians to keep track of all prescribed medications, and where possibly, simplify medication regimes.

Patient-specific standing orders are another means for primary care physicians and home health providers to work together to save time and reduce hospitalizations. Since a large percentage of home health patients have chronic conditions, exacerbations can be expected to happen at some point. Advance planning by physicians and home health nurses reduces the number of emergency calls to the physician and trips to the hospital.

"You can have standing orders for each level of how the patient's doing and keep them out of the hospital," said Dr. Winbery.

If these quality improvements resulted in one fewer hospitalization per home health agency per year, that could save Medicare $13.5 million dollars in Texas alone, Dr. Delgado said. He added that quality improvement efforts have already resulted in decreases in unnecessary hospitalizations. "For example, in the past 15 months, one home health agency in Texas has reduced its hospitalization rate by 73% by applying quality improvement techniques," he said.

Significant as the potential savings are, they are only part of the motivation behind the campaign. "This isn't just an effort to save money. It's also an effort to improve the quality of care," said Dr. Delgado.

He and other experts are convinced that closer cooperation between physicians and home health agencies will result in higher quality and more efficient care, while also pleasing patients by keeping them out of the hospital. "If given the choice of being hospitalized versus staying at home, patients prefer home to the hospital," said Dr. Delgado.

Challenges to improvement

The path to that ideal situation does have some obstacles, however, including many physicians' current perceptions of home care. "If there's one main theme among physicians about home health, it's mostly ignorance. There is sort of a tradition to send your patient to home health and expect not to hear from them until they're discharged," said Dr. Winbery.

The problem begins in training, where most physicians get little exposure to home health patients, said Dr. Coleman. The disconnect is exacerbated by primary care physicians' busy schedules and the compensation system, which is not set up well to reimburse physicians for time spent dealing with home health agencies.

"My general sense is that most physicians see home care nurses as the people who interrupt them during the day. That time keeps them later at night without any additional compensation," said Dr. Coleman.

There are efforts underway to remedy the reimbursement problems, like ACP's proposed advanced medical home, he noted. In New York, a pilot project conducted by the visiting nurses association helps physicians to track and log time spent reviewing records of home health patients.

But for the most part, QIO leaders are working to get physicians on board by spreading the word about how cooperation with home health care is good for their patients and their practices. Dr. Wenner conducts conference calls with physicians around the country to get their input on the quality improvement project. The campaign's Web site also offers physicians the opportunity to learn best practices for care of home health patients.

"With physicians, especially internists, I think you have to appeal to their desire to provide the best care for their patients," said Dr. Delgado. "Primary care doctors are very busy, but the folks who end up in home care are often very vulnerable and they need our attention."

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