Hospital Admits, LOS Cut With Home Care
AprIl 25, 2014
By Sarah Wickline, Staff Writer
Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania
SAN DIEGO -- An advanced illness management program for home-bound patients successfully reduced hospital admissions and lengths of stay, even though illnesses increased, researchers reported here.
• This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
• Note that this observational study demonstrated decreased hospital admissions among an elderly homebound population who were enrolled in a home-care management program.
• Be aware that the uncontrolled nature of this study limits our ability to draw conclusions about the efficacy of the intervention.
In a group of home-bound, advanced illness patients, the implementation of a managed care program led to a 37% reduction in hospital admissions, and an average of 1.5 fewer days in the hospital when admitted over the course of a year (8.9 versus 7.4) despite an increase in hierarchical condition categories (8% versus 18%), according to K. Sandy Balwan, MD, of North Shore-LIJ Health System in Great Neck, N.Y., and colleagues.
Balwan, who is also with Hofstra University in Hempstead, N.Y., discussed the advanced illness management program at the annual meeting of the Society of General Internal Medicine.
"We were charged with delivering high-quality, in-home care to our elderly patients with multiple chronic illnesses and functional impairment," Balwan said in a presentation.
As disease escalates into progressive, frequent complications, a frailty gap emerg
es. "This phase is characterized by multiple complications, multiple comorbid conditions, and frequent hospitalizations," Balwan said.
Patients in this group account for only 5% of patients in the North Shore-LIJ Health system, but 50% of total healthcare costs, she noted.
When Balwan's team set out to design the advanced illness management (AIM) program, the objectives they set were to create a clinical model to respond to changes in clinical status among these types of patients by utilizing real-time analytics to identify patients in need of higher-intensity services, and by using technology to improve care coordination and patient-specific metrics, which were measured in the following categories:
• Changes in hospital admissions
• Changes in hospital length of stay
• Communication with in-hospital providers
• Post-discharge medication reconciliation
• Patient satisfaction
• Incorporation of patient preferences into care
The AIM multidisciplinary team included seven doctors, three nurse practitioners, two social workers, and four administrative leadership and care coordinator partners to manage more than 900 patients across three counties.
In order to meet eligibility criteria for the AIM program, patients had to meet Medicare criteria for home-boundedness. Patients were prioritized based on clinical severity, hospital or hospice referrals, and not having a primary care physician.
The patients in the AIM program were an average age of 86 (range 23 to 110), 71% were women, 40% had diabetes, 27% had protein-calorie malnutrition, 26% had decubitus ulcers, and 23% had congestive heart failure.
"One of our biggest challenges was getting real-time information when our patients were admitted to the hospitals. In 2012, our patients were admitted to 21 hospitals," Balwan said. And the team was unaware of roughly one-quarter of those admissions.
By the third quarter of 2013, those unknown admissions decreased to 4% through patient and provider engagement; monitoring internal admission, discharge, and transfer (ADT) reports; and partnering with a regional health information organization, which alerted the AIM team with notifications of patient admission to any regional hospital.
Knowing when patients were admitted allowed for improved patient care coordination -- "in particular, post-admission contact with our inpatient providers," Balwan said. "In 2012, 45% of the 96 admitted patients had post-admission contact within 48 hours. By the end of 2013, that almost doubled to 88%."
In 2012, 63% of the 87 discharged patients received an in-home medication reconciliation within 48 hours after discharge . By the end of 2013, the rate increased to 90%.
Balwan and colleagues analyzed a subset of the sickest patients in the program for pre- and post-enrollment, and found a 37% reduction in hospital admissions and that the average length of stay fell by 1.5 days (8.9 versus 7.4) over the course of a year. This resulted in a reduction of 187 excess days in the hospital.
"We were able to see these improvements in spite of our patients getting sicker," Balwan said. At the start of 2013, 8% of patients had three or more hierarchical condition categories, which increased to 18% by the third quarter.
At the behest of patients, the AIM program also enabled more patients to be able to die at home as opposed to a hospital (54% versus 70%), "their express preference of where they wanted to die," Balwan said.
Patients were gi
ven satisfaction surveys in 2012 and 2013. The results showed improvements over time in the following categories:
• Received answers to medical questions the same day (45% versus 65%)
• Reduced trips to the ER (56% versus 65%)
• Visited within 36 hours for urgent problem (63% versus 71%)
• Likely to recommend the program to others (77% versus 84%)
"Implementation of an on-demand, advanced illnesses program can lead to decreased hospital admission rates, decreased length of stay, increased patient satisfaction, provide patient-centric care, and this can occur all in the context of increasing patient acuity," Balwan said.
Challenges to the operation of the program included a wait list longer than 100 patients, a 3-to-4-month wait for nonacute referrals, and a constant need to secure financing and leadership commitments.
One limitation of the study was the within-group analysis without a control group, Balwan and colleagues noted.
The authors declared no relevant financial conflicts of interest. Most of the patients in the program were supported by Medicaid.
Primary source: Society of General Internal Medicine
Source reference: Balwan S, et al "Bridging the chasm-advanced illness management: Higher quality, lower cost" SGIM 2014; Abstract Plenary Session I.