Home-based program offers care for complex patients
Team acts as extension to primary care providers
When Cigna HealthCare of Arizona Medicare Advantage members are homebound, have complex care management issues, or are at risk for readmission to the hospital, the home-based care team from Cigna Medical Group, located in Phoenix, visits the patients in their homes, assesses their needs, and arranges for the services they need to stay healthy and safe in the home environment.
"Seeing patients in the home environment gives clinicians a totally different perspective on the challenges these patients face in adhering to their treatment plan. They can pick up on issues that they never would learn about in the office environment," says Robert Flores, MD, medical director, population health for Cigna Medical Group. Cigna Medical Group the multi-specialty group practice division of Cigna HealthCare of Arizona.
The home-based program started about seven years ago with a focus on homebound patients who had complex medical needs, who were not visiting their primary care physician regularly. It has been expanded to include high risk patients who are being discharged from hospitals or skilled nursing facilities, and frail and chronically ill patients whose care is difficult to manage.
The home-based team includes physicians, nurse practitioners, registered nurses, licensed practical nurses, and social workers. They visit patients' homes and serve as an extension to the patients' primary care providers. The team can call in social workers, behavioral health specialists, pharmacists, or nurse educators when needed, as well as working closely with the disease management and case management programs in the health plan. "This program is built on a holistic model that looks at patients in their home environment and pulls in whatever services are necessary," Flores says. "We try to break down any barriers to care and collaborate with the patient's other practitioners to ensure that the patients get what they need and that we don't duplicate any services."
It often was difficult to understand what was going on with patients , says Sara Steffen, RN, MSN, GNP, ANP-BC, nurse practitioner, who saw patients in the primary care office before joining the home-based team. The patients weren't getting better when Steffen talked to them in the office setting. "Seeing them in their home environment helps me find out issues and challenges they face that they might be reluctant to tell me about," she adds. (For details on how Steffen works with patients, see related article, below).
When it comes to safety issues, it's more effective to have someone see the home environment, rather than relying on the patient's description of what the home is like, Flores says. Team members always conduct a safety evaluation, look for fall risks, and educate patients on the spot about fall prevention. They can arrange for modifications necessary to protect the patient's safety.
Cigna Medical Group analyzes claims data to identify Medicare Advantage members with extensive healthcare needs, who have not seen a doctor in a year, and patients who are being discharged from a hospital or a post-acute facility, who are at high risk for readmission or have gaps in transitional care. "Patients being discharged from a healthcare facility have become the largest population we manage now as opposed to those who are truly homebound," Flores says.
In addition, primary care providers refer patients who are frail and/or chronically ill who need more personal attention than they can receive in the primary care office, or who have special educational needs that can be delivered better in the home setting. "This group of patients can almost overwhelm the primary care provider in terms of managing them in a high quality way," Flores says.
The team members help patients arrange visits with their primary care providers and keep the primary care physicians informed about what's going on with the patient. "The primary care physician is still the main provider but uses the home-based team to fill in the gaps," Flores says.
Home visits help clinicians identify patient needs They pick up on patients' challenges When Sara Steffen, RN, MSN, GNP, ANP-BC, nurse practitioner on the home-based care team at Cigna Medical Group, based in Phoenix, visits patients in their home, she often realizes immediately that patients are facing a lot of challenges in their daily lives that make it difficult for them to care for themselves and adhere to their treatment plans. "Many patients are reluctant to ask for help, even if they need it. They won't admit that they can't pay for their medications or that they don't have food in the home," Steffen says. For example, some patients tell their primary care provider that they can take care of their activities of daily living but when Steffen visits the home, she can tell they are not able to do the cleaning or cooking. "I can look in the refrigerator and cabinets to see if they have an adequate supply of nutritious food, review their medication and make sure they are taking it correctly, and assess the home for safety issues," she says. "By visiting the home in person, I can tell if the patients are capable of getting bathed and dressed on their own and if they can take care of housekeeping and cooking meals." If the patients have psycho-social needs, she calls in a social worker to further assess the patient's needs and arrange for services such as caregivers, to help with housekeeping, bathing, and dressing, meals on wheels, help with transportation, or pharmacy assistance programs. The home-based care team has a unique opportunity to observe patients in their home environment and determine where problems occur, says Robert Flores, MD, medical director, population health for Cigna Medical Group. Flores tells of one patient who was visiting the emergency department frequently with symptoms that included dizziness, lightheadedness, and muscle weakness. Over time, the patient was examined by physicians in the emergency department, his primary care physician, and specialists but nobody could determine what was causing the symptoms. When he was referred to the home-based program, the nurse practitioner visited his home, completed an assessment, and asked to review his medications. She found a large number of sedatives and narcotics prescribed by multiple practitioners. After questioning the patient, she determined that he was overmedicating himself. She completed a medication review to find out which medication he should be taking, got rid of everything else, and educated the patient on the dangers of overmedicating. The patient, who had been going to the emergency department several times a week, has not been there for months. Steffen typically sees patients monthly or twice a month, depending on their needs. She may see stable patients every two months. The team sees the patients in person whenever needed but also works with them over the telephone. For example, nurses make outreach calls to patients with congestive heart failure to monitor their weight. If the patient has gained weight, Steffen may decide to increase the diuretic dose or see the patient in person. Then the nurse follows up by telephone to make sure the changes are working. Steffen determines when patients are ready to transition back to the primary care provider but if something changes and the patient needs more care, she gets the case again. "One of the major focuses of the program is to reduce hospital admissions by making sure the patients get the care they need, and that everything is in place to keep them safe at home," she says. |
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