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Community Health Network's discovery that 43 percent of its heart failure readmissions were driven by patients discharged home alone to self-care has led Community to risk-stratify all patients while in the hospital and visit their high-risk population at home.

Community and Central Maine Medical Center are two examples of healthcare organizations visiting medically complex patients at high risk of readmission in their homes, leveraging existing expertise and in some cases partnering with home health to include the patient's home in the care continuum.

New Horizons in Healthcare Home Visits profiles these two home visit interventions that are helping to reduce hospital readmissions and emergency room visits, while enhancing the patient experience.

HIN's 2013 Home Visits market survey found that 75 percent of respondents visit some percentage of patients or health plan members at home.

This 30-page special report examines the following programs:

• How Community Health Network reached across its system and leveraged existing home care experience to reduce hospital readmissions in recently discharged heart failure patients — a venture so successful it has been expanded to all heart failure clinic patients and will be rolled out to other chronic disease states in the future.

  In an interview with Lisa Collins, RN, MSN, chief clinical and operations officer of Community Home Health Services, and Deborah Lyons, network disease management executive director, the following aspects of Community Health Network's home visit program are discussed:

  • Replication of best practices from its award-winning licensed home care program under Medicare for CHF patients, including interactive voice response (IVR);
  • Modification of LACE readmission index to predictively identify patients at high-risk of readmission;
  • A 10-point risk assessment conducted by a Community transitional care nurse at admission to designate daily inpatient follow-up with high-risk patients;
  • Development of care plans for the high-risk that extends 30 days beyond discharge;
  • Linkage of home care and the comprehensive clinical, educational and safety assessment that takes place in the patient's home;
  • Patient engagement techniques for the homebound patient and caregivers;
  • Role of primary care providers in the home visit program;
  • Potential of electronic health records (EHRs) to improve communication and quality and consistency of care;
  • Results of the home visit program on both emergency room and hospital utilization by the heart failure population; and
  • Planned program enhancements and rollouts.
  
  
• How Central Maine Medical Center expanded a team already focused on outcomes improvement for 30-day readmissions to include providers, nurses, home care and hospice. The resulting intervention incorporates home health visits supplemented with telehealth, explains Susan Horton, DNP, APRN, CHFN, executive director of Central Maine Heart and Vascular Institute. This innovative work is also leading to other home-based interventions that are not restricted to individuals identifed by Medicare as homebound.

  Ms. Horton also covers the following program aspects:

  • Factors leading to the development of Central Maine's home visit program for recently discharged heart failure patients;
  • Tools and models adapted and employed to identify gaps in service and trends in heart failure and heart failure readmissions and to define Central Maine's heart failure patient population;
  • Creation of a consistent patient education guide that would provide uniform clinical guidelines in a health-literate fashion across all providers;
  • Partnership with home care and hospice that introduced telehealth to the home visit;
  • Typical tasks conducted during the home visit, including medication reconciliation;
  • Staff education and engagement;
  • Planned expansion, including use of telehealth in skilled nursing facilities for medication management, "on-demand" home visits and telehealth, and creation of clinical decision units adjacent to ERs;
  • Lessons learned from programs that can translate to other conditions, including AMI, COPD, pneumonia, and other heart diseases; and
  • Future partners in collaboration, including SNFs, family practice residents, and community paramedics.