Provider Home Visits to Reduce
Readmissions for High-Risk Patients
Michael Craig MD
1
MPH
and Michael Watson
3
C HEALTHCARER
X
2
MD
1University
of North Carolina School of Medicine, Chapel Hill, North Carolina
2C3HeathcareRx, Raleigh, North Carolina
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Home Visit Template
Background
Provider home visits can be used as an intervention
for reducing hospital readmissions but there is little
published data about their effectiveness
Intervention
Patients 18 or older admitted to WakeMed Health
and Hospitals in Raleigh, NC, and determined to be
high-risk for readmission by case manager or
discharging physician
Referrals encouraged for patients with:
• Frequent hospitalizations and ED visits
• No primary care follow-up
• Poor health literacy
• Significant psychosocial issues
• Complicated or high-risk medications
Follow-up phone call within 24 hours of discharge
Patients risk-stratified with scoring system modeling
on BOOST “8P” scale
Home visit arranged (within 2 days if high-risk, 4
days if moderate-risk and 5 days if low-risk)
Home visit completed by an MD or NP along with a
CNA
A patient navigator worked to insure patient had a
Primary Care Physician (PCP)
Patients had home visits and follow-up calls
continued until PCP follow-up or for up to 30 days
Prior to Visit
Review discharge summary
Clarify outstanding questions with hospitalist and/or home health if appropriate
Reminder call to patient or caregiver
Have all medications and medication lists available for review
Clarify address and time of visit
During Visit
Assess clinical status since discharge (problems, complaints)
Medication reconciliation
Follow up on any outstanding test results
Appropriate physical exam
Patient education
Disease processes and self-management
Warning signs and how to respond
Appropriate education material
Instructions for seeking emergency and non-emergency after hours care
Conclusion of Visit
Encourage PCP appointment
Paired Health follow-up (as indicated by care plan or provider discretion)
Provide patient with copy of clinical summary (paper and electronic)
Results
2013
2014
Overall
Intervention
Group
Readmissions (%)
Hospital Medicare
Readmissions (%)
Total Hospital
Readmissions
(%)
23 / 299
(7.7%)
36 / 605
(6.0%)
59 / 904
(6.5%)
1300/11268
(11.5%)
1397/11228
(12.4%)
2697/22496
(12.0%)
0.056
2148/26365
(8.1%)
2195/26034
(8.4%)
4343/52399
(8.3%)
0.002
Overall
p-value
• Average home visits per patient was 2.6
• Average time to first home visit was 2.6 days
14%
Readmission Rate
12%
10%
8%
6%
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Methods
Data was collected over two years
Primary outcome was hospital 30-day all-cause
readmission rate
• Only readmissions to WakeMed Hospital were
included (data on readmissions to other hospitals
was not available)
Readmission rate for home visit patients were
compared to the hospital’s Medicare readmission
rate and the overall hospital adult readmission rate
Process measures included number of home visits
per patient and time between discharge and first
home visit
4%
2%
0%
Year 1
Home Visits
Year 2
Medicare
Overall
All Adults
Conclusions
• High-risk population with home visits had better
readmission rate than Medicare patients and at least
equal readmission rate to total hospital population
• Limitations include lack of data on readmissions to
other hospitals and differences in the comparison
populations