Hospitals Look at House Calls to Reduce Expenses, Admissions
by Laura Landro; Wall Street Journal; 2/4/13

To help keep patients out of the hospital, health-care providers are bringing back refurbished versions of a time-honored exercise: the house call.

In addition to a growing quantity of doctors treating frail patients at home, insurers and health systems are sending groups of doctors, nurses, physician assistants and pharmacists into homes to monitor patients, administer treatment options, make certain drugs are being taken appropriately and evaluate risks for everything from slipping in the shower to family care-giver burnout. Some are adopting programs referred to as "Hospital at Home" to supply hospital-level treatment in the home, including portable lab tests, ultrasounds, X-rays and electrocardiograms.

In large part, the aim is to stay away from new financial penalties from the Centers for Medicare & Medicaid Services. Last October, the federal government agency began withholding specific payments to hospitals with greater-than-predicted readmission rates for patients with heart attacks, congestive heart failure and pneumonia. Nearly a fifth of its beneficiaries end up back in the hospital within 30 days, according to Medicare, costing $26 billion annually.

But there is also increasing demand to keep patients from being admitted to the hospital in the first place, especially if they have long-term disease. Such patients, particularly elderly ones, are more prone to bacterial infections and issues like bed sores in the hospital, and are in fact safer at home, experts point out.

"People may think of the house call as this quaint idea of a physician heading out in his horse and buggy, but it is an exceptional and necessary model for taking care of vulnerable high-cost patients," states Bruce Leff, a professor of medicine at Johns Hopkins University School of Medicine who formulated the Hospital at Home model and is president of the American Academy of Home Care Physicians.

Payment designs vary. Private insurers who contract with Medicare to offer benefits through Medicare Advantage programs may provide home-based care after hospital release. The Veterans Administration has a home-centered primary-care system for chronically ill veterans, and many VA centers operate Hospital at Home programs. Medicare has also been reimbursing a rising number of doctor house calls for fee-for-service beneficiaries and covers a handful of other home services after hospital release. A year ago, Medicare began a three-year demonstration project referred to as Independence at Home to test whether or not home-based care by groups of doctors, nurses and other clinicians can reduce the need for hospitalization, improve patient and caregiver satisfaction and reduce costs.

Existing research on house-call programs point to their positive aspects. A study released last June in Health Affairs showed that prices for patients in a Hospital at Home program at Albuquerque, N. M. -based Presbyterian Healthcare Services were 19% lower than for similar inpatients, in part because of shorter stays, and fewer laboratory and diagnostic tests. Patients with disorders including pneumonia, congestive heart failure and urinary-tract infections who are sick enough to require hospitalization and reside within 25 miles are "admitted" in their home. They are then visited daily by a physician and once or twice every day by nurses who provide infusions and execute routine lab tests and procedures.

Patient satisfaction ratings were also higher. "Patients who have been in the hospital numerous times realize it is not always the healthiest place for them and they are delighted to be at home instead," says Melanie Van Amsterdam, lead physician for the Presbyterian program and a co-writer of the study. They also get more time with physicians, who might expend a couple of hours on an initial visit as opposed to as few as ten minutes in the hospital, Dr. Van Amsterdam says.

Mercy Health, a not-for-profit health system in Cincinnati, Ohio that owns six hospitals, was in a position to reduce its 30-day readmission rate to 14. 5% as of November, from 16. 9% in 2011, with a Care Transitions system that assigns nurses to higher-risk individuals to keep them out of the hospital.

Verne Wisby, 68, suffers from persistent obstructive pulmonary disorder, a lung disease connected to smoking that can bring about respiratory infections and breathing trouble. He additionally has arthritis and chronic pain from a childhood automobile accident that broke his legs and hips and crushed his pelvis. He was accepted to the hospital last April after he came to the ER with a flare-up of his COPD, but within a month of his release, he was readmitted for a seizure.

At discharge, Mercy paired him with transitional care nurse Pamela Sevrence. On her first visit to his home, he was feeling so disheartened by his numerous medical problems, they both recall, he told her, "I'm simply going to sit here until I die." Ms. Sevrence worked with him to quit smoking within just 30 days, and advised Mr. Wisby and his spouse Bonnie in the use of oxygen and medications to avoid flare-ups in his lungs. She additionally fielded calls from Mrs. Wisby anytime a problem came up.

Ms. Sevrence lined up a new primary care doctor and a neurologist, as well as a pain specialist.

"She offered me hope, encouragement, and assistance," states Mr. Wisby. "I have no plan to go back in the hospital."

Health plans are also using claims information to identify patients at high risk for rehospitalization and helping organize care at home "so patients don't slide back," says Karen Ignagni, chief executive of America's Health Insurance Plans, an industry association.

For example, insurer Aetna AET +1. 66% is contracting with home health organizations to develop a transitional care program for customers of its Medicare Advantage program in a number of areas around the country. A pilot for the program decreased readmissions by 20% and saved $439 for each member. "It is expensive to send nurses into the household, but not nearly as costly as readmissions," says Aetna national medical director Randall Krakauer.

Cigna Medical Group, the medical practice unit of Cigna HealthCare of Arizona, with 25 health centers in the Phoenix area, has a Home-Based Care Team that consists of nurse practitioners and physician assistants. Robert Flores, the group's medical director of population health supervision, says primary care doctors use the team to help them manage patients at substantial risk of hospitalization or re-hospitalization who are unable to quickly get to a doctor's office. "We have lots of clients who would have undoubtedly ended up back in the hospital had the staff not been in their residences," Dr. Flores says.

The home team has made it easier for Sandi Roland of Mesa, Ariz., care for her 84-year-old father, Charles Wilburn, who came out of a six-week hospital stay a couple of years ago for numerous health problems. Ms. Roland says difficulties from that hospital stint left him in worse shape than when he was first admitted. A nurse practitioner came on a regular basis to begin with to help with bed sores, and check his blood and lungs, and a physical therapist helped with rehab.

"For me being a caregiver, it gives me a great deal of support and puts me at ease that if things were to go wrong I could call and they will come at any time," Ms. Roland says. The nurse continues to follow up with a call every 6 weeks and her dad has not returned to the hospital.




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