Visiting medically complex patients at home can shed light on health-related issues that might go undetected during an office visit, reducing the likelihood of unplanned admissions or emergency department visits by these patients.
The Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients outlines an innovative home visit pilot for Medicaid and dually eligible patients that reduced unplanned hospital admission days by 71 percent in
three months and provides key performance benchmarks on home visit activity in the healthcare industry.
In Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients, presenters Pam Aldridge, manager of care management at Durham Regional Hospital,
Larry Greenblatt, M.D., medical director for the chronic care program at
Durham Community Health Network for Duke University Medical Center, and
Jessica Simo, program manager with Durham Community Health Network
for the Duke Division of Community Health, describe the financial and clinical impacts of adding face-to-face interactions to a telephonic outpatient care management program, including:
- Substantially shortening hospital length of stay;
- Reducing number of unplanned admissions;
- Improving compliance with care plan;
- Reducing total cost of care;
- Reducing cost of hospitalization;
- Decreasing utilization in the outpatient setting, including a 95 percent decrease in clinic utilization and 60 percent decrease in ED utilization.
PLUS This 25-page resource provides industry benchmarks on home visits reported by 87 healthcare organizations in response to HIN's May 2010 Industry Survey on Care Transitions Management, including:
-
Who's Conducting Home Visits
-
Home Visit Frequency
-
Who Conducts the Home Visit
-
Top Tasks During a Home Visit
This resource will equip healthcare organizations with the data they need to make more efficient use of home visits, which are afforded further study in the 2010 Patient Protection and Affordable Care Act. The healthcare legislation includes funding for the Independence at Home pilot, which in coming years will test the feasibility of allowing chronically ill Medicare beneficiaries to receive primary care at
home.
The Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients provides specifics on the successful Care Partners home visit pilot, including:
- Targeted populations for home visits;
- Who should conduct home visits;
- Structure of the home visit;
- Security concerns;
- Patient assessment;
- Staff training;
- Alternatives to home visits;
- Clinical and financial outcomes; and
much more.
Table of Contents
-
Home Visits in the Patient-Centered Medical Home
-
The Care Partners Model
-
Assessing Program Effectiveness
-
Why Home Visits?
-
Target Populations for Home Visits
-
Safety Considerations for Home Visits
-
Home Visit Pilot Program
-
Results from Home Visit Pilot
-
Lessons Learned from Home Visits
-
2010 Benchmarks in Home Visits
-
Home Visits
-
Home Visit Occurrence
-
Who Conducts the Home Visit
-
Top Tasks During a Home Visit
-
Q&A: Ask the Experts
-
Excluding Unplanned Admissions
-
Use of Telehealth
-
Enrollment in Pilot and Control Groups
-
Staffing-Patient Ratios and Roles
-
Overcoming Resistance to Home Visits
-
Anatomy of a Home Visit
-
Targeted Populations for Home Visits
-
Factors That Influence Self-Management
-
Alternate Meeting Places
-
Future Program Enhancements
-
SNF Transitions
-
How Healthcare Reform Affects Home Visits
-
Glossary
-
For More Information
-
About the Presenters
