What It Takes to Prevent A Hospitalization in Managed Care Home Medicine

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What It Takes to Prevent A Hospitalization in
Managed Care Home Medicine

• Edward Ratner, MD
• Associate Professor, Univ. of Minnesota Medical
  School
• AAHCP Annual Meeting April 2008

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Case Study

• 87 year old retired Ob/Gyn professor with
  Alzheimers Disease moves from a senior high rise
  to an ALF. At transfer he is ambulatory and,
  with assistance, dresses in a suit (for work, he
  says) every day.
• A week later, he is reported to be febrile and
  not eating. He is found, fully dressed in bed,
  lethargic but without focal complaints. Labs and
  CXR are requested and Rocephin is prescribed, to
  be delivered by evening (with a return trip by MD
  to administer).

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Case Study

• The son, an OB in Boston, calls and requests
  hospitalization. Diagnosed with cholecystitis.
  Post-op complicated by delerium. Transfer to SNF
  and returns to ALF. Develops diarrhea,
  dehydration and re-hospitalized. C-diff treated.
• Family didnt like NH, patient returns directly
  to ALF, now needs assist with transfers and needs
  to be fed. Continued diarrhea.

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Physician Visits Since Last Hospitalization

• 3/28 Post-hospital assessment in bed
• 3/29 (Sat, 1PM) Found in bed, no PO yet today,
  pressure sore
• 4/4 Up, dressing on wound
• 4/9 Leg swelling -gt DVT on Doppler
• 4/10 F/U, D/C Lipitor and Metformin
• 4/13 (Sun) Family Conference, D/C Aricept
• 4/16 BP 80 palp, but able to walk, labs ordered

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Services Provided

• ALF RN (9-5) and HHAs
• Skilled home care (RN, ET, PT, Speech, HHA)
• Private Duty Home Care 8 hr/day -gt 4 hr/day
• Portable Xray, Doppler
• Lab
• Pharmacy (Lovenox, Coumadin, hydration)
• Medical Care and RN care coordination

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Summary

• To avoid hospitalization, need nearly
  hospital-level medical care
• ALFs may not be able to upgrade care with
  in-house staff
• Skilled and custodial home health agency care can
  substitute for non-surgical hospitalization
• Preventing a hospitalization requires a complex,
  coordinated team

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Budget for Managed Care Home Medical Team

• Staff Type of Patient Hours/mo
• Nurse New 2.5
• MD New 2.5
• Nurse F/U 1
• MD F/U 1
• Therefore, maximum case load is about 125 -150 /
  MD RN team
• MD pay should be PMPM visit (RVU vs. fixed rate)

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Strategies for Preventing Hospitalization in a
Home Medical Program
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Strategy 1. Advance Care Planning

• Routine advance care planning to define
  patient preferences and limits of care can
  prevent undesired hospitalizations. Some of the
  most severely disabled patients will opt to
  receive only the types of care that can be
  received in the ALF or home setting. Therefore,
  an advance care planning meeting, usually with
  family members, should be arranged within the
  first weeks after enrollment.

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2. Substitution of Hospital with Sub-acute
Nursing Home Care

• Waiver of the Medicare required 3-day hospital
  stay before coverage for nursing home care allows
  use of nursing home stays instead of some
  hospitalizations. Requires prior arrangements
  with nursing homes to accept patients on short
  notice, a process to handle paperwork for such
  transfers, transportation arrangements (even if
  on the same campus), and an agreement with the
  sub-acute nursing home physicians to provide
  hospital-quality assessment and monitoring of
  patients admitted for such care.

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3. Use of Urgent Skilled Home Care

• In the ALF and home setting, skilled home
  care can provide virtually all of the nursing and
  therapy services available in the hospital,
  although on an intermittent rather than
  continuous basis. The key to its use as a
  hospital alternative is timing same day
  admission to home care must be available.
  Acceptance of referrals after normal business
  hours is also necessary, in order for on-call
  physicians to be complete the process of making
  home health referrals.

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4. Urgent Hospice Admissions

• For patients with progressive, life-limiting
  illness, acute exacerbation or decline in
  function may make the patient newly eligible for
  hospice services, based upon prognosis. Since
  the Medicare hospice benefit will cover short
  term continuous care nursing, it may be an
  appropriate response avoid a hospitalization for
  an acute problem in a patient with a chronic
  illness. In some cases, hospice covered acute
  hospitalization (in hospital or nursing home) may
  be the most appropriate care level.

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5. Urgent Medical Home Visits

• The goal for timeliness should be to achieve a
  time from triage to on-site physician assessment
  that would rival the time to be evaluated for a
  similar problem in urgent care or an emergency
  room. For exacerbation of chronic illness
  (without chest pain, shortness of breath, or
  life-threatening vital signs), this would be
  approximately 4-6 hours.

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6. EMS Response Without Transportation

• An initial evaluation by paramedics may be
  appropriate to rule out emergencies such as heart
  attack, stroke, hypoxia, or obvious fracture that
  requires emergency room care. Prior arrangement
  with EMS providers to identify patients who
  should not be transported without first
  contacting the physician-on-call to discuss
  alternatives to hospital transport. It may be
  necessary to involve the health plan in such
  discussions to provide compensation for
  assessments without transport. Even when
  transport does occur, notification of the
  physician-on-call will permit timely
  communication between that physician and the ER
  staff to permit return home or transfer to a
  nursing home, rather than hospital admission.

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7. Emergency Room Care Without Hospital Admission

• For many problems, the emergency room
  evaluation and initial treatment is adequate to
  allow a patient to return home, if appropriate
  physician and home health follow-up is assured.
  Prior arrangements between ER staff or
  identification tools for patients (e.g. ID
  bracelets) and training of on-call team members
  can help deflect patients from hospital admission
  to other settings for post-ER care.

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8. Home Hospital

• A model that replicates hospital level
  nursing and physician care at home has been
  successful in an academic practice and overseas.
  This model provides continuous care nursing for
  at least the first several days of care and daily
  physician home visits. This intensity has been
  mandated to protect enrollees in research
  projects intermittent nursing visits several
  times per day and less than daily physician home
  visits are likely as safe in detecting need for
  hospitalization. Arrangements with skilled home
  care and/or extended hours agencies and creative
  reimbursement models will be made.

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9. Telemedicine

• Telemedicine has shown promise in preventing
  hospitalization for specific chronic illnesses
  (e.g focused on early recognition of exacerbation
  of diabetes, heart failure and COPD) through
  daily (or more often) electronic queries sent to
  patients by phone or to electronic devices
  combined with immediate notification of medical
  providers of markers of deterioration in
  condition. Such monitoring can also be performed
  by home health staff in ALFs
• The enhancement required to prevent
  hospitalization is a protocol for routine
  reporting to medical providers at first sign of a
  problem. Other telemedicine models include
  videoconferencing, which could enhance efficiency
  of physician visits, especially for urgent
  problems, to patients who have acute problems.
  Some health plan reimbursement models for
  telemedicine already exist, some new ones may be
  needed.

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Information Access for On-Call Physicians

• Some hospitalizations occur when an on-call
  physician is confronted with a chronically,
  severely ill patient who has a home health
  provider who thinks an exacerbation is occurring
  when there has actually been no change in
  condition. The on-call physician needs access
  to clearly documented baseline assessments of key
  functional and physiological parameters.

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11. Best-practice chronic illness and preventive
care

• Well-accepted guidelines exist for almost the
  major chronic illnesses and for general
  geriatrics preventive care. Tracking and
  reminder systems will be used to assist
  physicians in applying the large and growing
  number of recommendations.

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12. Polypharmacy Management

• Many chronically ill patients are taking a
  large number of medications which are potentially
  the cause for iatrogenic illness. As in nursing
  homes, a process to intermittently review
  medication profiles for problem drugs, doses,
  durations of treatment, and inadequate monitoring
  are needed. This may performed by physicians
  and/or consulting or dispensing pharmacists.

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13. Collaboration with Local Clinical Experts

• Local Medical Schools have expert team in many
  of the target diagnoses. Collaboration with such
  medical leaders from these clinics to assure best
  practice. For example, for patients with
  dementia, use of assessment tools and diagnostic
  determination protocols from academic Memory
  Disorder Clinic may enhance care. Similar
  approaches will be used for management of
  diabetes.

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14. Caregiver Support

• Title III and Medicaid may subsidize formal
  care giver support, to improve care plan
  adherence, prolong home care giving and/or reduce
  anxiety about exacerbations, which could lead to
  unnecessary 911 calls.