Valley Hospital brings back house calls in an effort to reduce readmission of heart patients

The Valley Hospital in Ridgewood has started making house calls to patients who have been discharged from the hospital — to make sure they’re having a smooth transition to their home environment, and don’t suffer a relapse that lands them back in a hospital bed.

Valley’s Mobile Integrated Health Program uses a team approach. The pilot program that began in August has hospital paramedics, accompanied by a critical care nurse and an EMT, making home visits to recently discharged patients with cardiopulmonary disease. The paramedics assess the patients’ home environment, making sure there are no hazards that could lead to a fall. And if the patients are in distress, the nurse can provide IV medication or a breathing treatment. Finally, the team makes sure the patients have the right medications, as well as the proper food in their kitchen if they’re on a restricted diet.

Like hospitals nationwide, Valley is striving to reduce patient readmissions. Medicare now imposes financial penalties on hospitals if their 30-day readmission rate is excessive, and making sure patients thrive at home after they leave the hospital is an important benchmark of health care quality.

Lafe Bush, Valley's director of emergency services, oversees the paramedics making the home visits. He said sending paramedics to help stabilize patients after discharge from the hospital is common in the Midwest. He said Valley may be the first New Jersey hospital to pilot this approach.

Robin Giordano, supervisor of Valley's heart failure program, said, “This population of chronically ill patients, who are generally elderly, have frequent bounce-backs to the hospital —which we know is not good for them.”

Bush said the home visit occurs within 24 hours of the patient’s discharge from Valley: “We evaluate them at home, and check to see if they are in any distress.”

If they are, the critical care nurse on the team can contact the doctor and start treating the patient. If necessary, the paramedics will transport the patient back to the Valley ER.

But if the patient is doing fine, the visit will focus more on education: surveying the home environment for safety hazards, installing grab bars in the shower, reviewing medication instructions, reminding the patient to make a doctor’s appointment. The team also will evaluate whether the patient is a candidate for visiting nurse care, which is provided by Valley Home Care, or might need a home health aide for bathing and meal preparation.

“This is a one-time home visit to make sure you’re on the right path and guide you to the next step,” Bush said. “It is part of the continuum of care.”

Giordano said the program addresses the major issues that send patients back to the hospital:
“Generally, patents don’t come back because of some illness; it is because some basic needs are not being met.”
Medication issues, for example: The patient may not understand the meds, or hasn’t gotten a new prescription filled and is still taking the meds from before they went into the hospital.

“Another thing that brings people back is their home environment not being safe; patients will come back within days of going home because they’ve fallen,” Giordano said.

Or the patients may be readmitted because their condition has taken a turn for the worse.
Giordano said the team will ask, “Who is the care person at home: is it your son or your daughter or your neighbor?” For those who have no support system, the team may get a social worker on the case.

Bush said the program is starting with heart failure and pulmonary disease patients and, eventually, “We want to expand this to everybody, regardless of their diagnosis.”

Right now, Valley is covering the entire cost of the home visits, but Giordano predicted that eventually this will be covered by Medicare and commercial insurance

This is the latest in a number of programs by Valley to reduce readmissions. And Giordano said they are having an impact: Valley now has a 30-day readmission rate of 22.3 percent, down from 26.4 percent 18 months ago.

Peter Southway, 80, of Wyckoff, got one of the first Valley home visits in August.

“It was excellent — they took my blood pressure and did an EKG and said my heart was fine,” Southway said. “They made me feel very comfortable. After you get home, they check to make sure you’re OK. I think it’s a good idea.”

source