1. Home Visits: Filling the Quality Gaps between the Hospital and the PCP Jessica Macrie DO, MPH Mark Robinson MD

2. Transitions of Care are Difficult Continuity of care is lacking in the inpatient setting Communication between discharge team and the patient is suboptimal Communication between discharge team and the PCP is suboptimal despite D/C summary Medication reconciliation is a challenge throughout the hospital stay EMR systems do not share information seamlessly from inpatient to outpatient

3. Local Problems at CFM Discharge summary in Cerner difficult to print Patients arrive at the office without med list and it takes a lot of time to reconcile the d/c summary med list with the EMR med list Patients cannot recall hospital interventions Timing of follow-up visit not always correct Patients did not get needed DME supplies in timely manner “Follow-up Hosp” visits were routinely a disaster taking long periods of time (not a 15min visit)

4. Consequences of poor hand- offs Hospital readmissions are a problem Hospitals soon will not be paid for certain Medicare readmissions How big of a problem is this?

5. Rehospitalizations among Patients in the Medicare Fee-for-Service Program Analysis of Medicare claims data from 2003-4 19.6% of 11.8 million Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, 34% were rehospitalized within 90 days. Estimated cost to Medicare for unplanned rehospitalizations in 2004 was $17.4 billion Jencks S et al, N Engl J Med 2009;360:1418-28.

6. Can we design an intervention aimed to improve transitions of care and in the process decrease number of readmissions?

7. Hypothesis Home visits by a mid-level provider after discharge will improve the quality of the transition from the inpatient to the outpatient settings, and increase patient and provider satisfaction with the process.

8. Intervention Goals Complete med reconciliation at home Decrease medication errors after discharge Correct med list in EMR before the patient returns to the office Use mid-level provider to “find and fix” things Ensure accurate timing of follow-up visits Improve hospital readmission rates within a large, community-based family medicine practice.

9. Melissa Woodard, FNP

10. Location of FMCs Mt. Pleasant

11. ~350 bed community hospital/medical center Only hospital in the county with population of 172,000 4 residency clinics admit to one common inpatient service Average daily census of ~35 patients on Family Med Service CMC – NorthEast Medical Center

12. Methods A Nurse Practitioner makes home visits to patients recently discharged from the hospital. (~48hrs) She brings EMR into the home, updates problem lists and medication lists to assist the hand-off to the PCP Protocol checklist: Comprehensive medication reconciliation Assess needs for equipment, referrals, and nursing or rehabilitative services. Confirm/schedule appropriate follow up OV Discuss discharge diagnosis and planning Provide patient education for self-management of their chronic disease.

13. Methods (cont) Home visit findings are communicated to PCP via EMR and documented in patient chart. Any medication discrepancies or missing orders are corrected by the NP at the visit, with input from PCP or hospital attending as needed. Project Team: 1 Nurse Practitioner, 1 administrative support person, multiple physician advisors, 1 data-entry person

14. Inclusion Criteria (initial plan) Patient admitted If readmission, automatically scheduled for post-discharge home visit If admission for CHF or with >8 meds, Medicare or Medicaid, automatic home visit scheduled If inpatient team is concerned about transition of care after discharge can order home visit to be scheduled Patient discharged Home visit done within 48 hours of discharge

15. Monthly home visits Sept 2009-July 2010

16. Inclusion Criteria (evolved) All discharges from our inpatient service scheduled for home visit unless: Discharge to SNF Mother/baby Patient refusal Patient home is outside of predetermined radius

17. Study Outcomes N=236 home visits in 10 months Mean age=67.0 69% female, 31% male Average time in home per visit = 28 min Does not count travel time, chart review time, scheduling

18. Number of Medication Errors by Patient n = 236 40% with 1 or more

19. Types of Medication Errors

20. Care Coordination Services N = 236

21. Care Coordination Services (continued) N = 236

22. Home Visits by week

24. Patient Satisfaction Patient questionaire (n=56) – Was the home visit helpful? 100% YES – What is your overall rating of the care you received from this home visit? 95% very satisfied, 5% satisfied – Is this a service you would recommend we continue for all of our hospitalized patients? 100% YES

25. Provider Satisfaction Provider questionaire (n=45) – Was the information helpful? 100% YES – Did this home visit improve your satisfaction with this patient’s hospital follow up visit to you? N=39 51% very satisfied, 36% satisfied, 13% neutral – Did this home visit help to save time in the follow- up visit? N=33 70% Yes, 30% No

26. Readmission Rates

27. Revenues Medicare reimbursement = $65.44 per visit - CPT 99348, mid-level provider Medicaid funding of $24,000 annually, per contractual arrangement

28. Expenses Nurse Practitioner Salary (0.8 FTE) $ 56,000 Scheduler Salary (0.2 FTE) $ 7,072 Benefits (@ 30% salary) $ 18,922 Annual mileage reimbursement @ $400/mo $ 4,800 Total Direct Cost of Program* $ 86,794 *Excludes billing costs and other overhead costs

29. Annual Contribution Margin

30. Discussion Using a nurse practitioner meant many issues could be resolved immediately – Prescriptions written or corrected – Home health or DME ordered – Billable visit Home visit was documented and signed within EMR – No extra papers to locate or sign – Medication list, problem list and visit summary is updated and readily available for PCP visit

31. Obstacles Need for administrative support in scheduling Safety issues for clinician in the home Patient misunderstanding (n=1) Cost to the practice Too many cooks for a new recipe that changed over time

32. Successes Highly valued service by patients Able to catch and fix things: – medication errors, DME, timing of follow-up Helped physicians with hospital follow-up visits Service copied by our hospital Opportunity to collaborate going forward

33. Future Plans Resident quality project: standard simple discharge note sent to PCP in EMR 1 of 17 Beacon Grant communities Participate in hospital wide intervention Nurses and nurse practitioners Create a collaborative around readmissions Complete case review of readmissions for further insights about preventing readmits

34. Further Reflections on Readmissions Sent home too soon (disease process, functional status) Medication Errors Multiple “insolvable” chronic diseases Progression of disease (death spiral) Failure to plan end of life goals Belief that medicine can fix anything Social Factors (poverty, neglect, loneliness) Mental Illness co-morbidity

35. The End Jessica Macrie, D.O. Mark D. Robinson, M.D. Cabarrus Family Medicine Residency Concord, NC

36. Questions to consider How do we decide when someone is ready for discharge? How might we risk stratify patients? What do we do with mental health co- morbidity? Opportunity for intervention? How many readmissions are preventable? What is your hospital doing to work on this problem?

37. The Care Transitions Intervention Eric A. Coleman, MD, MPH; Carla Parry PhD, MSW; Sandra Chalmers, MPH; Sung-Joon Min, PhD Randomized controlled trial of 750 community- dwelling patients aged 65 or older Post-discharge intervention used “transition coach” to follow patients from hospital to home for first 28 days post discharge maintain continuity of care and ensure health needs were met, using home visits and phone calls. Intervention patients had lower rehospitalization rates at 30 days and at 90 days than controls. Coleman et al Arch Intern Med. 2006;166:1822-1828

38. Readmission rates Intervention 30 days8.3% 90 days16.7% 180 days25.6% Same diagnosis 30 days2.8% 90 days5.3% 180 days8.6% Controlp value 11.9%0.48 22.5%0.04 30.7%0.28 Same diagnosis 4.6%0.18 9.8%0.04 13.9%0.046 Coleman et al Arch Intern Med. 2006;166:1822-1828.

39. Further Application of Care Transitions Medicare fee-for-service population Age > 65, admitted to one hospital in CO, non- psychiatric ward Community dwelling with telephone, speak English No dementia or hospice plans One of 11 diagnoses: stroke, CHF, CAD, dysrhythmia, COPD, DM, spinal stenosis, hip fx, PVD, DVT, PE Parry C et al Home Health Care Services Quarterly 2009;28:84-99.

40. Further Application of Care Transitions: Intervention Health coaching model www.caretransitions.org Four Pillars 1.Reliable medication self-mgmt system 2.Patient-centered record owned by pt 3.Timely f/u with primary or specialty care 4.Unambiguous list of “red flags” of worsening condition and how to respond to them Parry C et al Home Health Care Services Quarterly 2009;28:84-99.

41. Results N=98 randomized 49 intervention, 49 usual care Mean age 82 Groups similar in Age, gender, demographics, health conditions 15% self rated health as poor LOS index hospitalization (6.2 v 7.2days NS) Parry C et al Home Health Care Services Quarterly 2009;28:84-99.

42. Readmission rates Intervention 30 days6.8% 90 days9.3% 180 days20.9% Same diagnosis 30 days2.3% 90 days2.4% 180 days2.4% Controlp value 16.7%0.15 31.0%0.01 38.1%0.08 Same diagnosis 9.5%0.20 19.0%0.03 23.8%0.008 Parry C et al Home Health Care Services Quarterly 2009;28:84-99

43. Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program Randomized controlled trial set in tertiary metropolitan hospital in Australia N=128 patients (64 intervention, 64 control) Acute medical admission, aged 65 or older and at least 1 risk factor for readmission Comprehensive nursing and PT assessment with individualized exercise program prescribed Nurse-conducted home visit and telephone follow-up commencing in hospital and continuing for 24 weeks after discharge Courtney et al JAGS 57:395-402, 2009

44. Results Measured emergency health service utilization and health-related quality of life at week 4,12 and 24 weeks post discharge. Intervention group required significantly fewer readmissions and emergency GP visits. Intervention group reported significantly greater improvements in quality of life than controls. (based on scoring of Medical Outcomes Study 12-item Short Form Survey (SF-12v2)) ReadmissionsER visits Intervention Group22%25% Control Group47%67% p-value0.007<0.001 Courtney et al JAGS 57:395-402, 2009

45. References Ashish K. Jha, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D. Public Reporting of Discharge Planning and Rates of Readmissions N Engl J Med 2009;361:2637-45. Benbassat J.,MD, Taragin M. MD, MPH. Hospital Readmissions as a Measure of Quality of Health Care Arch Intern Med/Vol 160 Apr 24 2000 Eric A. Coleman, MD, MPH; Carla Parry, PhD, MSW; Sandra Chalmers, MPH; Sung-joon Min, PhD “The Care Transitions Intervention: Results of a Randomized Controlled Trial” Arch Intern Med. 2006;166:1822-1828. Mary Courtney, PhD,_ Helen Edwards, PhD,w Anne Chang, PhD,wz Anthony Parker, PhD, Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program J Am Geriatr Soc 57:395–402, 2009. Health care reform likely to penalize hospitals for readmissions HOSPITAL CASE MANAGEMENT ™ September 2009 129-132. Jencks S, Williams M, Coleman E. “Rehospitalizations among patients in the Medicare fee- for-service program.” N Engl J Med 2009:360; 1,418-1,428. CARLA PARRY, PhD, MSW, SUNG-JOON MIN, PhD, Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For- Service Setting, Home Health Care Services Quarterly, 28:84–99, 2009.

46. Denmark: Home visits to elderly after discharge from hospital Age 75+ visited by nurse 1 day after discharge, visited by GP 2 weeks after discharge Control group usual care 1 year outcomes admission to Nsg Home N=163 intervention, N=181 control Medical, surgical, orthopedic, gynecology departments Hansen FR et al Age and Ageing 1992;21:445-450.

47. Results No difference in readmissions < 14 days No difference in total numbers of readmissions No difference in mortality Intervention group: – 10 vs 24 admitted to SNF by one year (p<0.05) – 1950 vs 2700 days in SNF Hansen FR et al Age and Ageing 1992;21:445-450.

48. Readmission rates Our intervention cohortJenks et al 30 days41/23217.7%19.6% 90 days40/34.0% 180 days14/44.8% Same diagnosisColeman et al 30 days10/2324.3%2.8% 90 days5/5.3% 180 days4/8.6% Jencks et al N Engl J Med 2009:360:1418-28 Coleman et al. Arch Intern Med. 2006;166:1822-1828