Primary Care Program

 Care Coordination 

Visiting Nurse Health System in Atlanta, Georgia.
Agency Description:
As Georgia's leading nonprofit provider of health care at home, the mission of Visiting Nurse Health System (VNHS) is to improve the lives of those served. VNHS cares for patients and their families in 26 metro area counties. VNHS provides in-home nursing care, rehabilitation, primary care, and hospice services. They also operate the Hospice Atlanta Center, a 36-bed inpatient facility in Brookhaven, Georgia. VNHS cares for all who need services, regardless of diagnoses or financial circumstances. The Jesse Parker Williams Foundation initially provided $100,000 for this project.
Population Impacted:
This program targets mobility-challenged, chronically ill seniors in the greater Atlanta region. VNHS provides these seniors with primary care in their home. In 2012, the program cared for 262 patients—primarily in DeKalb and Fulton Counties. A typical patient is age 80 or older, has at least seven chronic conditions, takes an average eight medications daily, and has had at least one hospitalization in the past year. Sixty-two of these patients were concurrently participating in the Independence at Home (IAH) demonstration.
Project Description:
Without access to primary and preventive care, seniors can succumb to a cycle of inefficient care delivered episodically via visits to the emergency department, brief hospitalizations, and discharges home without proper follow-up care. As a result, approximately 18 percent of Medicare patients are readmitted to the hospital within 30 days of hospital discharge. Readmissions adversely affect seniors’ health and peace of mind, undermine their ability to live independently, and result in excessive Medicare spending. The HouseCall program prevents this type of crisis-driven care through a proactive approach that facilitates ongoing, regular monitoring of seniors' health. 

Specific benefits to this program include:
  • Increased access to care
  • Decreased emergency room visits and hospitalizations
  • Disease management education
  • Peace of mind for patients
  • Cost savings
There are a myriad of benefits from enacting this program in Atlanta. A survey conducted of patients stated that 74 percent had not seen a PCP in the previous year. Once in this program, each patient receives six to 12 visits from either a PCP or Nurse Practitioner (NP) per year in their home. Another added benefit is fewer hospitalizations and a decrease in emergency room visits. Since they receive timely medical attention in the home, approximately 80 percent of patients avoided hospitalization or an emergency room visit.

Each time a patient is seen by a clinician is an opportunity for disease management education. The clinician can give the patient a quick lesson in their specific disease management or answer any questions while in their home.
Outcome Measures:
In the spring of 2013, 70 primary care patients were randomly selected to receive patient satisfaction surveys. Twenty-nine patients returned the surveys (a 41 percent response rate), which revealed the following:
  • 69 percent of respondents stated they were always or usually able to be seen in their home within 36 hours of contacting the office for care; 36 hours is the benchmark for receiving timely care set by the American Academy of Home Care Physicians. 
  • 93 percent of respondents stated that the ability to receive medical care in their home has improved their quality of life. 
  • 86 percent of respondents reported high satisfaction with the amount of time their primary care provider spent with them.
  • 90 percent of respondents reported consistent interaction with their family/caregiver.
  • 79 percent of respondents stated the services have reduced their trips to the emergency room.  
VNHS receives Medicare claims data on the portion of primary care patients participating in the IAH demonstration project. The most recent data received contains information on 62 IAH patients during the time period of June 1, 2012 through February 28, 2013. This data shows that 69 percent of patients (43 of 62) avoided a hospitalization and 84 percent of patients (52 of 62) avoided an emergency room visit during this time period. Updated data for patients in both programs will be available in the spring of 2017.  
Barriers to Implementation:
Barriers to this program include issues with clinical reporting software. VNHS had issues with providing staff education on for software utilization. VNHS also had difficulty in enrolling eligible patients to participate in the program. This low patient census caused staffing shortages. As there were no patients to see, two nurse practitioners left the program.