Readmissions plunge with resident house calls
Residents visit at home the day after discharge
A Downey, CA, medical practice has found that old-fashioned physician house calls dramatically reduce hospital readmissions of elderly patients.
The preliminary study of 100 patients showed that the one-day readmission rate dropped by more than 70% and one-week readmissions fell by 41% when discharged patients were visited in their homes by a medical resident, says Donald S. Furman, MD, director of medical affairs for CareMore Medical Group.
CareMore is a group of more than 150 primary care physicians and 200 specialists in 25 offices throughout the Los Angeles area. The group provides care to more than 10,000 senior citizens through a proprietary managed care plan.
The house calls effort is an offshoot of the group’s Comprehensive Care Clinic, which provides intensive medical care to patients who are chronically ill with conditions such as diabetes, heart disease, and pulmonary problems.
Targeted patients receive at least one house call by a medical resident, beginning the day after discharge. The resident visits the patient along with the regular home health team and consults by telephone with a CareMore hospitalist who treated the patient in the hospital. The resident and the hospitalist make any medical decisions.
During the home visit, the physicians often find problems the home health nurses missed, partly because they are seeing the patients for the first time. "The first day, the home health nurses have 20 pages of regular paperwork. They haven’t seen the patient in the hospital, so they don’t know if they are worse or better," Furman says. The residents are familiar with the patients because they have treated them in the hospital, he adds.
Because the practice uses resident physicians, there is no cost to the medical group.
"But there is a huge benefit to the residents. They are used to working in the office and hospital environment, and they have no idea of what is going on in the home," Furman says.
The medical group started the house calls program at the beginning of 1999 after discovering that 53% of patients who were readmitted to the hospital were within a week of discharge and that 24% were readmitted within one day.
The length of stay for the team’s patients was half that of similar patients from other medical groups in the area.
"We were looking for what was missing. We wanted to find out why they were being readmitted," Furman says.
At CareMore, the treatment team for the elderly patients includes a hospitalist, a case manager, a social worker, and a clinical pharmacist, as well as physicians who see patients in the clinic and a home health nurse.
"This allows us to envelop the patient with care. Most of our senior patients need social, psychological, and functional care. We try to give them the highest quality of care at the level they need," Furman says.
The hospitalists are a key part of the program, Furman adds. The hospitalist team sees the frail elderly patients at clinics as well as in the hospital. Hospitalists see all frail diabetics in the diabetic clinic and supervise the anticoagulation clinic.
When an elderly patient is admitted to the hospital, the hospitalist, case managers, social workers, and home health staff meet every day to review the patient’s care and condition. Those who are deemed frail are selected for the physician house call program. The resident and the home health team arrange to meet at the home.
"There’s no question that it’s made a difference having a physician visit them at home," Furman says.
The elderly patients are readmitted for a multitude of reasons, Furman says. During the initial visits, the residents have discovered that some patients were taking the wrong medication or the wrong doses because they hadn’t read all the written discharge information.
"We can see first-hand how patients function in their own home. We can make sure the home is safe from objects like throw rugs and misplaced electrical cords, which could cause a patient to fall and break a hip," Furman says.
When patients do get ill within the first week, the medical team can intervene to prevent hospitalization or cut the length of the hospital stay, Furman says.
The house calls work well because there is a comprehensive team approach to care, Furman says.
"Just sending a physician out with no case management or home health wouldn’t work. Our program works so well because it is within the whole spectrum of programs for the elderly," he adds.
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