Home Visiting Provider Program

 Care Coordination 

Christiana Care Visiting Nurse Association, Camden, Delaware.
Agency Description:
Christiana Care Visiting Nurse Association (VNA) is a full-service home health agency and a wholly-owned subsidiary of the Christiana Care Health System in Delaware. Average daily census is approximately 1,600 and approximate annual revenue is $45 million. The Home Visiting Provider Program is included as a component of the Christiana Care Quality Partners ACO.
Population Impacted:
The key population impacted by this program is the frail and elderly in the greater Wilmington area. The Home Visiting Program has served 1,004 patients since June 1, 2012. The two charts below outline the current patient population by zip code and the enrollment and growth of the program since June 2012. 

Strategic Partners:
Key strategic partners for this program are the home health agency, the hospital, physicians, and other providers. The chart below highlights the referral sources for the program, as well as percentages of patients from each referral source.

Program Description:
This program takes primary care directly into the homes of homebound, high-cost patients. The majority of patients have multiple chronic conditions and many cannot leave their homes. Enrollment in this program is completely voluntary and the patient is not required to give up their doctor or any benefit.
The purpose of this program is to support patients who choose to age in place or receive care in the home. This program provides timely care to reduce the need and incidence of ED visits and in-patient hospital visits. This program also provides consistent care at home through the coordination of physician, social work, home health, rehabilitation, phlebotomy, and radiology services, as well as appropriate ancillary services.

The program has been extended to five years total and may be further extended based on the potential extension of the Independence at Home program Christiana Care is concurrently running. The goal of year one was to enroll up to 200 patients (a required minimum for the program). Another goal of year one was to build up appropriate staffing; working with VNA to integrate home care and home visit services and working on the CMS-related requirements and various offices tracking processes.

The goal of the program for year two was to focus on decreasing the readmission rate. Year three is devoted to developing a care management and palliative care program to address the most frequent users of ED and in-patient services. New goals and measures are being developed for subsequent years.

Implementation of this program is funded by the Christiana Care Health System CEO discretionary funds.

The patient outcomes results for those enrolled in this program is a decrease of both in-patient services (10 percent decrease) and ED use (three percent decrease).

Outcome Measures:
Hospital and ED admissions were initially reduced as indicated in the results graph. Subsequent initial data indicates further reduction of hospitalizations to below 18 percent for 30-day readmissions.
Barriers to Implementation:
Should the project yield strong, long-term evidence of service delivery efficiency, continued project operation should benefit from accommodations within infrastructure, including systems modifications and resource allocations.