Home care lowers ED visits for asthma
April 1, 1999 6 minutes read
Home care lowers ED visits for asthma
Pediatric program boosts outcomes
Administrators at a New Jersey home care agency found their new asthma disease management program for children made winners out of everyone involved.
Young patients feel better; parents learn how to keep their children healthy; the hospital saves emergency department resources better spent elsewhere; and home care staff can see real, positive improvements. And because staff were convincing about the cost-savings potential, insurers agreed to pay for the services participants would receive at home in order to control their disease.
Valley Home Care in Paramus, NJ, developed its program because childhood asthma is a common problem in the hospital-affiliated agency’s northern New Jersey service area.
"Asthma is one of the biggest reasons for missed school days and absenteeism," says Rose Marie Ranuro, RNC, MSN, PNP, director of maternal and child health for Valley Home Care, which is affiliated with Valley Hospital in Ridgewood, NJ. The agency serves two counties in northern New Jersey.
"We’re in a large metropolitan area here with lots of cars and buildings, so asthma is a very hot topic," Ranuro adds.
The agency tackled the problem by devising a program for a home care team to educate and support families of asthmatics. The program has worked so well that after its first year, the children involved have had 66% fewer admissions to the emergency room.
Family education was crucial to the program’s success. But it also had to be done within two or three visits to meet reimbursement requirements, says Marianne E. Vafiadou, RN, Valley Home Care pediatric asthma nurse.
Ranuro and Vafiadou offer this advice on how to start an asthma program:
1. Develop a plan and form a team.
First, Valley Home Care formed an asthma team that includes Vafiadou, a social worker, and a nutritionist. Other nurses are trained in asthma care and are given an asthma nursing skills competency checklist at orientation, after three months, and annually.
The next step is to conduct surveys, collect data on asthma cases, and include this information in the plan, Ranuro says.
Home care agencies must prove to payers their intervention will result in decreased hospitalizations and visits to the emergency room and physician. So an agency should collect baseline data on asthma cases and continue to collect data as the home care team visits patients.
The plan also calls for finding alternative sources of funding. Valley Home Care applied for grants with the local United Way and the hospital’s foundation and is awaiting approval.
2. Market program to providers, community.
Valley Hospital sometimes refers asthmatic children to home care when it looks as though they’re becoming sick frequently. But the agency needed to bring more patients into their program. Staff went into the community to let local physicians and patients know that their help was available.
"We do many talks in the community about asthma, its prevention, and teaching," Ranuro says. "Sometimes we have family members say, I’d love for you to come over, do one-on-one teaching, and evaluate my home environment.’"
The asthma team also established a monthly support group for asthma. This educates families of asthmatic children and fosters greater community awareness of the disease. The support group has speakers, including specialists. Through these outreach programs, the team established good relationships with family practitioners, pulmonologists, and allergists.
If parents of an asthmatic child call the agency asking for services, the agency will contact the family’s physician. "We’ll say, We met so and so, and the family is asking for case management, would you be willing for us to make a home care evaluation and get back to you with a report?’" Ranuro explains.
3. Convince payers it pays.
As the program matures, it will collect more data that can be used to prove to insurance companies that home care visits will save them money in the long term, Ranuro says.
The program is controlling costs as well as disease. Before the program was available, 20 patients incurred $50,408 in hospital bills related to asthma episodes. Another 12 patients later added $21,119. The cost was only $11,748 to control the first 20 patients through the program, and the costs of the newcomers are expected to drop as well.
But for now the agency has been contacting payers on a case-by-case basis: Once the agency has obtained a physician’s order to treat the asthmatic child, a nurse will contact the insurance company and explain the situation, Ranuro says. "We say, Johnny Jones has been diagnosed with asthma; you may not be aware that we have an asthma program, and this is what we plan to do.’"
Savings must be quantifiable
The payer typically will approve one evaluation visit, even if they are unconvinced case management is necessary, Ranuro says.
One obstacle is that many larger payers have their own case managers who may or may not be skilled nurses. If a payer balks at paying for three visits and telephone case management for one year, then Valley Home Care will provide the service anyway, Ranuro says.
Besides the altruistic intentions, the program has to be uniform in how patients are treated in order for the agency to collect the most useful outcomes data, Ranuro explains.
"With the data, we can say we saved the system X amount of dollars and conducted X number of visits in one year," she says.
Also, the asthma team might be able to convince a payer to pick up some home care visits when it appears a child is becoming very sick, Ranuro says. "We might say to the insurance company, It looks like Johnny Jones is getting sick; would you like to authorize a visit because the doctor might hospitalize him if he doesn’t seem to be getting better?’"
4. Set up visit schedule.
Valley Home Care has created a care map that lists goals for three visits for pediatric asthma patients, including extensive education during each visit.
The asthma team uses three visits as a goal but will add more visits when necessary. "We should be able to get everything done in three visits and sometimes even two visits," Vafiadou says. "It depends on the severity of the child’s asthma and the family’s cognitive ability."
The first visit lasts two hours and includes a thorough evaluation of the patient, family, and home environment. The nurse also assesses which other disciplines may be needed.
The nurse assesses these types of conditions:
— Do the parents smoke?
— How many pets are in the house?
— Is the home cluttered or dusty?
— Are there problems with rodents or cockroaches?
— Are the closets messy?
— Do the parents have any emotional support?
— Can they afford medications and asthma equipment?
— What type of pillows does the child sleep on?
— Are the medications working?
— Is there unusual stress in the child’s life?
These are the types of questions that a nurse can answer much more easily after visiting a family than if a physician relied on the family’s self-reporting.
Vafiadou had been involved in one case, for example, in which a parent was not telling the family physician how many asthma episodes the child was having between visits. It took a home care visit to get to the bottom of the problem.
The nurse writes a report within 24 hours after the visit, gives the physician a copy of the evaluation, and gives a written and verbal report to the insurance company.
The second and third visits build on the first visit’s instructions and may include a visit by the social worker or nutritionist.
The follow-up visits also give the nurse an opportunity to see if the nurse’s suggestions have worked for the family and if there are any improvements in the home environment. Nurses may even visit the child’s other environments during follow-up visits. For instance, she might visit the homes of grandparents or baby sitters.
5. Follow up with phone calls.
Vafiadou says phone calls are important in helping the family control the child’s asthma. She might make as many as 30 telephone calls to the family over the course of a year. (Each call lasts about 15 minutes.)
Typically, the asthma nurse will call the family at least once every two weeks, Ranuro says. When nurses call, they follow a telephone visit protocol the team developed. (See asthma telephone visit sheet, inserted in this issue.)
The telephone contact helps to reinforce the team’s message that the family should call the nurse or home care agency whenever they notice signs that could lead to an asthma episode, Ranuro says.
"We like to let them know that before you get to the point of an ER visit, you should be in touch with us," she says. "They are good about calling before it’s an emergency."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content