Housecall Providers has a statistic from our participation in the Independence at Home (IAH) National Demonstration Project that we are excited to share. Preliminary numbers (10 months) are showing that Housecall Providers’ 200 IAH patients have nearly half (45%) of the 30-day hospital readmission rates of our non-IAH patients. We are thrilled that the hard work of our transition team, especially transition nurse Mary Sayre RN, has made such a positive impact on the health of our IAH patients who have been hospitalized. “This truly is a team effort – being part of the transition team has allowed me to be the eyes and ears for the primary care provider (PCP).” Sayre stated.
In daily practice, our transition team starts by developing relationships with the patients and especially their caregivers, reviewing Physician Orders for Life-Sustaining Treatment (POLST) forms for needed updates, and coaching them to call Housecall Providers when a crisis occurs rather than just calling 911. In some cases, Mary is able to make an urgent visit to assess a patient if their PCP is not available. When a patient needs to go to the hospital, a member of the transition team makes contact with the ER giving a report to the doctor, faxing essential records and at times is literally handing the physician copies of essential records (POLST, med list, problem list, most recent encounter) while advocating for this information to follow the patient if they are admitted. All along this process, they are informing the PCP about the patient’s condition and receiving input to share with the hospital staff. The transition team’s goal is to visit the hospital daily and work with the staff on a discharge plan, which many times may lead to a palliative care or hospice admission. In most cases, the PCP or Mary makes a home visit within 48 hours of hospital discharge, reconciles the medication list and troubleshoots any unforeseen issues.
“Because of the digital age we have far less face to face contact and this can be especially true in the medical arena,” Sayre continues. “Patients moving through different systems and places have the potential for greater miscommunication surrounding their medical history and current condition. Having a medical professional walk with them through every step, providing pertinent information and building trust based relationships has been extremely rewarding as well as very successful in lowering the 30-day re-admits”
We look forward to sharing more of our future successes with you as the demonstration moves forward.