December 16, 2019

A Helping Hand for the Homebound

Jim is a 70-year-old patient with Multiple Sclerosis (MS). As his wife and caregiver Jean explains, Jim’s condition has progressed to the point that it takes considerable coordination and effort to get him to the doctor’s office. This causes them both a great deal of anxiety and stress. “I’ve often said…I wish these people sitting at desks only knew the challenge involved in getting to an appointment just to fulfill a Medicare requirement,” she says.

How can we address the needs of elderly patients who are unable to travel to regularly scheduled visits at their primary care practice? Care managers at Newton-Wellesley Hospital began to puzzle over this question in 2016 as they noticed an increasing number of homebound patients enrolled in their high-risk care management program (known as the Partners HealthCare Integrated Care Management Program or iCMP). For patients who are considered homebound, leaving the home requires a considerable and taxing effort, which can lead to isolation and increased vulnerability.

This condition results in the loss of what clinicians call “eyes on the patient,” which can negatively impact many aspects of a patient’s health and wellbeing. Consequences may include worsening of chronic conditions due to lack of routine medical management, medication non-adherence, and an increased likelihood of a chronic condition turning into a crisis (resulting in otherwise avoidable emergency department visits or inpatient hospital admissions).

Innovation for an Unmet Need

While Partners has previously established home care programs, nothing existed to meet the unique needs of these complex, chronically-ill, homebound patients. Recognizing this problem, the Newton-Wellesley iCMP team saw an opportunity to innovate. They set out to create a primary care-driven service that would provide routine, scheduled medical management and address care coordination needs in patients’ homes. The “Home Visits for the Homebound” pilot was born.

Jennie Wright, RN, ACM, who helped launch the pilot in conjunction with the Newton-Wellesley Medical Group, explains that other Partners programs like the Partners Mobile Observation Unit or Home-Based Palliative Care have discrete teams that visit patients’ homes for acute care episodes. However, these programs are not substitutes for primary care and can’t provide long-term management of chronic issues the way a primary care provider could.

“In many cases, these homebound patients have been going to the same primary care practice for 20 years,” says Wright. “We wanted to figure out a way to preserve that link between the patient and the practice, which makes patients more comfortable and avoids interruption of care.”

A team comprised of primary care-based Nurse Practitioners and Physicians Assistants (also called Advanced Practice Clinicians or APCs) identified existing homebound patients who would be appropriate for the pilot. With experimental and control groups running from March 2018 to September 2018, a total of 61 home visits were completed with 45 unique patients. Although specific services varied from patient to patient, many visits included cognitive assessments, assessment of social needs for things like financial assistance or housing status, behavioral health counseling, skilled home care, lab work, and advanced care planning conversations. Patients’ caregivers, who were often present at the visits, were highly involved in the pilot. They assisted with scheduling, received appointment reminders, and communicated with the care team during and after visits.

Quantifying Results

The results of the pilot showed that patients in the experimental group were more likely to have had a recent visit with their primary care team, and on average had seen a primary care provider more frequently and more recently. Other significant outcomes include the following:

  • Rates of emergency department and inpatient hospital admissions for patients in the experimental group decreased by 18% and 41%, respectively, after patients had received their initial home visit.
  • The mortality rate of the experimental group was significantly lower than the mortality rate of the control group (2% vs. 30%).
  • Patients in the experimental group were more likely to have completed a Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, as documented in their electronic health record.

Evaluating Impact

A post-pilot survey was also distributed to providers, patients, and patients’ caregivers to gauge the impact of the program on each of these important stakeholders. Despite the change in location of care, most patients (73%) reported that the quality of care they received in the home was either better or the same as compared to the doctor’s office. Additionally, 92% of patients and caregivers reported that they would recommend this program to other patients in need.

Participating in the Home Visits for the Homebound pilot has helped Jim and Jean tremendously by bringing the clinicians to their home, making it much easier to get regular check-ins both for Jim’s MS and other routine concerns. “We are fortunate that this program has been made available to us,” says Jean. “We have already met with the Nurse Practitioner and RN Care Manager, and we consider them a lifeline.”

From the providers’ perspective, feedback revealed that 100% of respondents reported being very satisfied with the quality of the home visits that patients received, with 70% saying it had a “highly positive” impact on their overall satisfaction with practicing medicine. Additionally, all providers noted that “building a relationship with other members of primary care team while co-attending visits” was an extremely positive or positive experience.

“Both the qualitative and the quantitative feedback that we received from providers was very positive,” says Kaitlyn Schweikert, a project specialist who worked on the pilot. “Every single provider said they would be interested in continuing the program, so that was really exciting.”

The Bigger Picture

These outcomes suggest that the pilot was successful in improving the care of homebound patients, relieving the burden on patients’ caregivers, and increasing care coordination among providers. Beyond that, this pilot is just one example of how Partners is thinking about the larger issue of frailty.  

“Speaking with folks across the organization who work in primary care, I’ve found that we’ve all been dealing with an increasing number of patients who have frailty,” says Wright.

Frailty— clinically defined as an accumulation of deficits across multiple physiological systems—results in increased patient vulnerability and heightened risk for adverse events like falls or other serious accidents. It is a major contributing factor to those who become homebound, and also causes patients to suffer disproportionately from the effects of fragmented health and social care.

Wright says, “It’s really exciting that the Partners system is coming together to look at frailty on all different levels.”

As the demand for home-based care continues to grow in tandem with the aging population, Partners will continue to refine its existing home-based care programs, develop collaborative relationships among them, and create new ones to successfully meet the needs of our frail patients.

“The homebound pilot is a great example of a program that truly meets the needs of individual patients and families who are struggling with these issues, and I’m excited to see how we can take the lessons we’ve learned and apply them to other programs,” says Wright.



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