Case Management

Hospital starts team home visits to reduce readmissions

Case Management Insider, May 19, 2015

Paying a visit to patients in their homes can help keep them out of the hospital, according to Valley Health System in Ridgewood, New Jersey.

The health system recently began a program that sends medical teams, comprised of a paramedic, critical care nurse and emergency medical technician, to check up on recently discharged patients. The program focuses on two groups at high risk for readmission. The first group includes patients suffering from cardiopulmonary disease who don’t qualify for home services or turned them down.
 
“Patients with cardiopulmonary disease, particularly those with heart failure and chronic obstructive pulmonary disease, are particularly vulnerable to re-hospitalization, especially during the transitional period after they first arrive home,” said Lafe Bush, director of emergency services at Valley and a paramedic, in a written statement.
The second group the hospital recently added are patients who underwent a transcatheter aortic valve replacement (TAVR) procedure, a less-invasive alternative to symptomatic aortic valve stenosis.
 
“Our TAVR patients often have multiple health problems, and their post-op care can be very complex,” said Mary Collins, supervisor of cardiothoracic surgery and the cardiovascular screening program at Valley. “This unique service offers an advantage to these patients who are not only recovering from their heart valve procedure, but also must continue to cope with and manage their existing health problem. Early clinical assessment and appropriate intervention prevents complications and allows these patients to continue to recover at home.”
 
The hospital developed this initiative in an effort to prevent readmissions. Some 25% of patients in the U.S. suffering from heart failure wind up back in the emergency department within 30 days, according to a study of Medicare data cited by hospital officials.
 
The program, a joint initiative between the hospital’s department of emergency services and Valley Home Care, seeks to reduce that risk by intervening early to head off potential health programs that might otherwise result in a return hospital visit.
 
During a visit, the team not only assesses the patient’s physical condition, but also ensures the home is safe and the patient understands all of his or her treatment instructions and can follow them. The team also ensures the patient scheduled a follow-up appointment with his or her physician.
 
The program is part of a larger integrated healthcare initiative that includes other services such as skilled nursing care, telemanagement, rehabilitation, and cardiac home care diabetes support, among others.
 
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