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The American Journal of Managed Care August 2012
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Lisa M. Kern, MD, MPH; Adam Wilcox, PhD; Jason Shapiro, MD; Rina V. Dhopeshwarkar, MPH; and Rainu Kaushal, MD, MPH
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Home Care Program for Patients at High Risk of Hospitalization
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Home Care Program for Patients at High Risk of Hospitalization

Stuart Levine, MD, MHA; Bernard A. Steinman, PhD; Karol Attaway, MHA; Tyler Jung, MD; and Susan Enguidanos, PhD
Randomized controlled trial of a home care program for managed care patients resulted in lower probability of hospital admission and greater patient satisfaction with care.
Objective: To assess the efficacy of a home care program designed to improve access to medical care for older adults with multiple chronic conditions who are at risk for hospitalization.


Study Design: Randomized controlled trial in which participants were assigned to the home care intervention (Choices for Healthy Aging [CHA]) program or usual care.


Methods: The intervention group consisted of 298 older adults at risk of hospitalization as determined by a risk stratification tool. Measures included satisfaction with medical care, medical service use, and costs of medical care.


Results: The intervention group reported significantly greater satisfaction with care than usual care recipients (t test = 2.476; P = .014). CHA patients were less likely than usual care patients to be admitted to the hospital (25.6% and 37.1%, respectively; P = .02). There were no differences in terms of costs of care between the home care and usual care groups.


Conclusions: Provision of home care to older adults at high risk of hospitalization may improve satisfaction with care while reducing hospitalizations. Lack of difference in medical costs suggests that managed care organizations need to consider targeting rather than using risk stratification measures when designing programs for high-risk groups.


(Am J Manag Care. 2012;18(8):e269-e276)
Potential benefits of providing medical care in the home include reduction of hospitalizations and improved patient satisfaction with healthcare.

  • Compared with usual care patients, managed care patients receiving a home care intervention were less likely to be admitted to the hospital and had greater satisfaction with care.

  •  However, there were no differences in terms of costs of care between the home care and usual care groups, suggesting that managed care organizations need to consider targeting when designing programs for high-risk groups.
Advanced age is often associated with greater likelihood of acquiring chronic disease. Previous studies have reported that by age 65 years, the majority of individuals have multiple chronic conditions1 that could require services from an array of medical providers and higher healthcare expenditures. In addition, many chronically ill older people perceive managing their illness as beyond their ability.2 Many aspects of the current healthcare system have been ineffectively designed to monitor and treat chronic conditions that may involve multiple medical specialists. The relative lack of attention to care coordination has led to poorer health outcomes in the United States relative to costs of care.3

The Patient Protection and Affordable Care Act holds significant implications for healthcare providers regarding improvement in quality of care.4 Through a series of incentives and mandated reporting on quality indicators, healthcare providers will have greater accountability for the quality and costs of care provided. For example, beginning in 2012, managed care providers, health plans, and hospitals will be fiscally accountable for hospital readmissions. As this deadline approaches, effective methods to improve and manage care for high-risk patients with multiple chronic conditions are urgently needed. Additionally, the Patient Protection and Affordable Care Act seeks to improve both quality and continuity of care through the development and testing of new models, including service delivery models, that use home-based primary care physician and nurse practitioner teams to achieve higher quality and lower costs of care. These recommendations arise from a growing body of literature attesting to the need for home-based healthcare delivery systems to better respond to individuals with complex healthcare issues.5,6 Providing in-home primary care to high-risk, chronically ill patients has been found to improve quality of care and patient satisfaction, although impact on healthcare costs is mixed.7,8

This study assessed the effects of an interdisciplinary team that provided care in the home for chronically ill patients at high risk for hospitalization. We hypothesized that patients who received care via the Choices for Healthy Aging (CHA) program would report greater satisfaction with services and have fewer hospitalizations and emergency department (ED) visits, resulting in reduced costs of care compared with the costs for usual care recipients.

METHODS

A randomized controlled trial was conducted to test the effectiveness of the CHA program for reducing medical service use and improving satisfaction with care among a high-risk group of patients enrolled in a managed care organization located in Southern California. This study was approved by the institutional review board of the research organization working with the managed care health plan.

Research Site

This research was conducted within a management services organization that manages and operates medical groups and independent physician networks nationally. The study was conducted among 3 Los Angeles County regions of the management services organization.

Eligibility and Enrollment

Potential participants were identified from a pool of patients by using an electronic risk assessment screening process developed and tested by SCAN Health Plan (for more information see Predicting the Financial Risks of Seriously Ill Patients).9 The assessment tool identified frail older adults at high risk for use of medical services by using an algorithm that considered variables such as age, sex, number of medications, number and types of chronic conditions, and use of EDs and inpatient hospital services. Patients were initially contacted by telephone and were provided with information about the study. Interested participants provided written informed consent for study participation. Participants were randomized into either an intervention or control group using a computer-generated randomization chart.

Our primary hypotheses included improving satisfaction with medical care and reducing hospitalizations and costs of medical care. Based on the cost savings reported by Brumley et al,7 with a 2-sided, 2-sample t test at an alpha level of .05, a power level of 0.80, and an effect size of r = .16, we required a total of 216 patients to complete the study, 290 after adjusting for attrition rates.7

Study Groups

Intervention Group. The CHA program was adapted from an evidence-based home-based palliative care program found to be effective in improving patient satisfaction, decreasing deaths in the hospital, and reducing cost of care among patients in the last year or two of life.7,10 The home-based palliative care program also demonstrated that provision of interdisciplinary care was effective in shifting the locale of care from acute care settings to home and community environments, a place of care much more aligned with the needs and wishes of many severely ill patients.

Goals of the CHA program were built on the home-based palliative care program model and included the following activities: (1) early identification and treatment of exacerbation of the illness, (2) patient-specific health education, (3) selfmanagement or caregiver management of the disease, and (4) advance care planning and other psychosocial issues. Care was delivered via an interdisciplinary team, with core team members consisting of a physician, nurse practitioner, nurse care manager, and a social worker.

Within 5 days of a patient consenting to the program, an initial home visit was made by a home care physician, nurse care manager, and social worker. The physician conducted an initial medical assessment and provided acute treatment needed for stabilization and palliation. The nurse followed with patient and family education, advance care planning, assessment of medications management need, and treatment adherence of patients. The social worker conducted a biopsychosocial evaluation, including an assessment of the patient’s living condition, level of caregiver support, and mental status. Treatment plans were developed in consultation with the patient and family. The plan addressed care for acute and chronic conditions experienced by each patient, with special attention to palliative care as needed. In addition, all medications were reviewed and monitored to ensure that participants were taking correct medications and dosages and were aware of potential side effects.

A physician/nurse practitioner team, in coordination with a nurse care manager, was responsible for conducting followup home visits at least once a month. During these visits, the nurse provided medication reconciliation, disease education, and advance care planning, and assessed the patient for warning signs of hospitalization. A social worker also visited the home once a month, on average, and provided patients and their families with information and referrals to supportive services in the community. Other team members made less frequent visits and telephone calls. The clinical team conducted weekly meetings to ensure continuity of care and coordinated treatment plans among the various healthcare providers treating the patient, including the patient’s primary care physician, specialists, and other providers/services such as durable medical equipment, home healthcare, pharmacy, and case management. Finally, a physician with a nurse care manager, medical assistant, and social worker acted as personal care advocates of the patients, facilitating coordination of appointments with specialists and other service providers.

The home care physician was available to visit 24 hours a day, 7 days a week, and also made regularly scheduled home visits as medically appropriate. Patients and caregivers were provided with the physician’s cell phone number, enabling easy access, and patients and families were encouraged to contact their home care physician any time to ask questions about their healthcare or address exacerbations. The initial intake was conducted within 1 to 2 home visits, and each intervention participant  eceived at least 1 visit once per month, more depending on need and acuity.

Usual Care Group. Patients assigned to the usual care group received the standard care for which they were eligible, provided by their medical group. That included the usual primary care, home healthcare, hospice, ED, and hospital care.

Measures and Data Collection

Data were collected from patient interviews and from the electronic databases maintained by the medical group. Interviews were conducted via telephone immediately following receipt of the informed consent form (at enrollment) to collect demographic and satisfaction information at baseline; these interviews were repeated at 6 months. Undergraduateand graduate-level research assistants, blinded to group assignments, were recruited and trained to conduct telephone interviews with patients. Interviews were approximately 15 minutes long.

Sociodemographics. Sociodemographic characteristics of patients were collected during the baseline survey, including participants’ age, sex, marital status, race/ethnicity, education level, income level, living arrangement, and social support. Living arrangement referred to the type of housing and household composition. Social support was determined by asking patients who their primary caregiver was.

Satisfaction With Medical Care. Satisfaction with medical care was measured using the Home Care Satisfaction Measure.11,12 The scale measures patient satisfaction with the overall primary care team and was administered to participants in both the treatment and control groups. Dimensions of care assessed by the Home Care Satisfaction Measure included choice, information/education, emotional support, coordination/continuity of care, problem solving, and overall quality.

Medical Service Utilization and Costs. Service utilization data were collected retrospectively from the management services organization electronic databases at 12 months following program enrollment. Service data included number of ED visits, physician office visits, and hospital days. These variables were coded and analyzed as continuous variables and dichotomized for logistic regressions. Due to varying payment mechanisms for hospital claims as well as clinician costs, actual costs were not available. Estimates for total costs of medical services were computed using proxy costs that represented average expenditures per utilization of inpatient and ED care. CHA intervention visits were recorded in an electronic database (for physicians and nurse practitioners) and through the use of a program electronic log for social workers, aides, and case managers. Proxy costs for intervention visits by discipline were calculated based on actual time recorded per visit for social workers and case managers, and for average visit and commute/travel times for nurse practitioners and physicians. Average hourly salary for each discipline (including benefits) was multiplied by either the actual hours recorded (social workers and care managers) or the average visit time (physicians and nurse practitioners). Clinician time included telephone, travel, and in-person time incurred in provision of patient care.

Analyses

 
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