Primary care at home keeps patients safe

Primary care at home keeps patients safe

Program targets medical, psychosocial needs

After a pilot project resulted in a 47% decrease in emergency department visits and inpatient admissions for 90 at-risk patients, Priority Health, a Grand Rapids, MI-based health plan, is expanding its home-based primary care program in which a team of providers cares for patients in their home.

The program began as a pilot with Spectrum Health Medical Group and a group of 90 patients with advanced illness and has expanded since then to include more than 200 patients, says Mary Cooley, RN, BSN, associate vice president for care management and operations. Spectrum Health Medical Group provides care for patients in a three-county area in western Michigan. Most of the patients in the program are members of Priority Health’s Medicare Advantage program, although some are covered by Medicaid or private insurance.

Patients in the home-based primary care program have advanced chronic illnesses and multiple medical conditions that are complicated by functional or cognitive limitations. "They not only require complex medical care, but are unable to access care. Many are functionally challenged, isolated without a lot of caregiver support, and are no longer able to drive. Their situations make it difficult for them to adequately access traditional modalities of care," Cooley says.

The program goes beyond just providing medical care for the patients and works to line up all the medical and social services the patients need to live safely at home. A team of providers including a primary care physician, a nurse practitioner, a registered nurse case manager, and a social worker see the patients in their homes and provide whatever medical services they need. In addition, the program has partnered with a psychiatric provider, a volunteer organization, and the local emergency medical services to provide support whenever the patients need it.

"This program is fundamentally changing the way care is delivered. It’s a holistic approach that provides all of the support patients need in their homes. The program harnesses the support of the entire village. It’s a team-based model that leverages the resources available in the community," Cooley says.

Using claims data and the knowledge they have about the members, the care managers at Priority Health send primary care providers a list of patients who may be appropriate for the program, Cooley says. The providers review information they receive from the health plan and refer patients to the program.

The interdisciplinary team meets every Monday and reviews all of the patients, including those who have just been referred to the program, she says. The team determines the best clinician to make the initial visit to the home. In most cases, the case manager is the first to visit and conduct the assessment. If the patient has a lot of social issues, the social worker may make the first visit.

The goal is to visit the patients within 72 hours after they are referred to the program, Cooley says.

The first clinician to visit the patient conducts a comprehensive health assessment, a full assessment of his or her cognitive abilities, and a thorough assessment of the living situation to ensure that the patient is living safely, she says.

The home visits are an essential part of identifying patient needs, Cooley says. "Many can button their shirts and comb their hair, and they seem OK when they have a 10-minute visit at the doctor’s office. But when we get into the home and see how they are living, we recognize that they have many needs," she says.

The team reviews the information from the assessments and develops an individual plan that includes all of the patient’s medical and social needs, she says. The patient’s primary care physician signs off on the plan. The case manager coordinates all of the provider visits and other services the patient needs and calls on the social worker to assist with managing social needs, which run the gamut from housing support and transportation issues to assistance with cognition deficits.

At their weekly meetings, the team reviews the progress of patients in the program and revises the care plans as needed, she says.

Patients in the program receive routine and preventive care in their homes, 24-hour-a-day support, education about their conditions and medication regimen, telemonitoring if appropriate, and other in-home services including occupational, physical, and speech therapy, Cooley says.

A key part of the program is a rapid response protocol to provide support 24 hours a day, seven days a week. The protocol is based on what the team anticipates that each patient is likely to need after normal business hours, she says.

"For instance, if the patient has heart failure and has been admitted to the hospital multiple times for fluid volume overload, we determine what potentially will happen and what supplies, such as furosemide, will be needed if the patient needs stabilizing after hours, and place them in the home. If the patient or family member calls at 2 a.m., we can contact the emergency medical service who will deploy a clinician to the home to administer the medication that will stabilize the patient’s fluid levels," she says.

Keeping patients safe in their homes is a top priority, Cooley says. "That is non-negotiable. We have to make sure they are safe even if it means arranging for someone to touch base every day to make sure they are eating and taking their medication," she says.

For instance, if the patients are isolated without a caregiver and no family nearby, the case manager enlists the volunteer corps to send someone out to visit the patient at regular intervals. The volunteers are mostly from local churches, Cooley says.

"Our goal is to keep these patients at the highest threshold of wellness and provide whatever support they need so they can live well in the community and avoid having to go to a nursing home. We understand their barriers to healthcare and staying well, and work to help them overcome the barriers and stay out of the emergency department and the hospital," she says.