Physician Home Visiting/Chronic Care Management Program

 Care Coordination 

North Country Home Health & Hospice, Littleton, New Hampshire.
Agency Description:
North Country Home Health & Hospice (NCHHA) is a private non-profit home health and hospice agency providing visiting nurse services, home health care, rehabilitation, home health aides, personal care, homemaker, and companion care programs, as well as a hospice program. NCHHA is located in Littleton,  New Hampshire, which is in the rural North Country, White Mountain area of the state and serves 22 towns which are primarily large, geographic areas with small populations. The patient case load shows a 20 percent higher population of chronic care patients than in other parts of the state. The average daily census is 250 patients. Several patients are served as a part of the New Hampshire Rural ACO population.
Population Impacted:
The primary population for this program is NCHHA’s chronic care homebound clients who have difficulty accessing physician services. Many of the patients have wound care issues, medication issues, or exacerbation of their chronic disease. Most patients have limited resources to manage their disease. The patient population is in the rural and mountainous North Country of New Hampshire in which travel and access to public transportation is difficult. The patients are receiving some type of home health services either through Medicare, Medicaid, private insurance, or some of our grant programs.
Strategic Partners:
Ammonoosuc Community Health Center in Littleton, New Hampshire provides the physician collaboration and home visits. This is crucial to the success of this program in managing and improving the chronic care outcomes of our mutual patients. A physician champion has been identified to lead the program and provides the majority of the physician home visits. Littleton Regional Health Care is also a partner in leading the care transition meetings in which we have developed common patient education tools, care management strategies, and identifying "frequent flyers" to the Emergency Department whom this program would benefit.

The agency currently contracts with a local community health center and physician practice that is billing for physician services under Medicare Part B. NCHHA has applied for local grant funding to expand the program.
Project Description:
The physician home visiting program and chronic care management was developed by NCHHA in collaboration with Ammonoosuc Community Health Center to address the needs of chronic care patients.  Through in-home collaboration with the physician and nurse or therapist, this program provides improved communication among these disciplines with the patient and their family by developing a coordinated approach to care planning, education, and tools that are focused on mutually agreed upon outcomes. The physician home visiting program also provides joint case management visits with the nurse or therapist, in addition to physician home visits, to patients who may otherwise not get to see their physician provider. This limits the nurse and physician's ability to provide a collaborative approach to care. The program supports education and training to both the home health agency clinical team as well as the physician home visiting partners on areas that address best practices in home health and care planning for chronic care patients. The next level of the program to be implemented through the current grant funding proposal will support this training for the care staff such as home health aides and homemakers. The long-term goal of the program is to have all involved in the care management of chronic care patients be trained with the most current strategies and approaches to chronic care management, with a focus on team collaboration and patient-directed care.
The program began in July 2013 and to date 63 patients have had interventions through this collaborative approach. Sixteen percent of patients would have needed to go to the hospital emergency room if these interventions had not been provided in the home. The agency has seen a reduction in the hospital readmission rate of three percent. Littleton Regional Healthcare has also seen a reduction in their hospital readmission while partnering with the agency on this project with its care transitions program. The patients included in this collaborative approach have had wound care issues, cardiac disease exacerbation, medication issues, and care management issues.
Outcome Measures:
There was a three percent reduction in the hospital readmission rate and also a one to two percent increase in most of the home health compare reportable outcomes.
Barriers to Implementation:
The biggest challenge was the physician's buy-in and comfort level in having another provider conduct the home visit for their patient. However, once they saw the benefit of this collaborative approach and the time savings, referrals for the program began to improve. The other barrier was funding. The Medicare Part B funding is only for one-hour billable- type visits, which does not cover many of the care planning visits. Using technology like handheld ECG machines has helped, but funding continues to be a barrier to grow and expand the program. Although the savings related to improved patient outcomes and decrease in patient rehospitalization is beneficial, increased funding through grants and other sources will be needed for future sustainability of the program.