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The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission

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April 7, 2022
Summary

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.1 Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.2 Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.2

Building on prior studies, a team at the Cleveland Clinic Health System (CCHS) implemented a home visit program, called High Risk Transitions in Care (HRTIC), with the goal of reducing 30-day hospital readmissions for discharged patients at high risk for readmission.2 The program aimed to leverage the scope of practice of advanced practice registered nurses (APRNs) along with acute care skills offered by paramedics.

The innovation evolved in two phases. In the first phase, the CCHS team experimented with a model that offered three home visits provided by either APRNs or paramedics in the first four weeks following discharge. After five months in Phase 1, the CCHS team found no significant difference in readmission rates for the participating population when compared with a matched cohort.2 In Phase 2, CCHS adapted the innovation by delivering a total of four home visits to referred patients within 30 days of discharge. APRNs provided the first post-discharge home visit, and paramedics, in coordination with the APRN and the patient’s larger care team, often provided subsequent home visits.2 After six months, the home visit program was associated with about 10% fewer readmissions when compared with a matched cohort.2

Beyond the additional home visit, the CCHS team believes that a key reason that the Phase 2 results were encouraging was that the patients received care from both types of providers, receiving both the APRNs’ skill as independent practitioners to diagnose and treat illnesses and the paramedics’ rapid response capabilities and acute care experience.

To evaluate the longer-term effects of the HRTIC program, the CCHS team compared readmission rates 60 and 90 days after hospital discharge for the Phase 2 group with those of a matched comparison group. Readmission rates did not differ between the two groups, indicating a potential need to extend visits beyond four weeks to sustain outcomes.2

Factors that contribute to sustaining a successful program, according to the CCHS team, include a centralized referral system that utilizes an administrative team to schedule the home visits. The team said the innovation requires flexible criteria for identifying high-risk patients in case the criteria need to be adjusted because the program does not have the capacity to serve the existing volume of referred patients. In the future, the CCHS team would like to explore the reasons patients decline home visit programs and strategies for increasing patient participation.

Innovation Patient Safety Focus

The focus of the HRTIC program is to reduce preventable 30-day hospital readmissions (i.e., readmissions in the first 30 days following discharge) of patients at highest risk for readmission.

Resources Used and Skills Needed

The CCHS team reports that the following resources and skills are needed to implement the HRTIC program:

  • Processes and a tool for identifying the highest risk patients. The innovation used the CCHS readmissions risk calculator, which factors patient information on prior utilization, comorbidities, insurance, and a variable to capture language barrier, poor health literacy, or cognitive impairment.3
  • APRNs and paramedics to make the home visits
  • Infrastructure, including a centralized referral and care coordination system and staffing, a program coordinator, communication channels for coordination between providers, standardized reporting procedures, measures of progress, and methods for data collection
  • A protocol for scheduling home visits. For example, once a patient agrees to participate, the home visit care coordination team should contact them within a few days to schedule an initial visit.
  • Training for referring providers and the care coordination team that addresses strategies for working with patients who are reluctant to participate.
  • Cultural competency and tailoring communication to the patients’ level of health literacy are also crucial skills for the home visit teams in their work with patients.
Use By Other Organizations

Numerous health systems have post-discharge home visit programs.4 The Cleveland Clinic Home Visit Program uses a unique staffing structure consisting of APRNs partnered with paramedics to provide ad hoc and planned home visits along with nurse care coordinators for referral and care coordination.

Date First Implemented
2018
Problem Addressed

CCHS established the program to support patient health and prevent avoidable hospital readmissions in the weeks following hospital discharge.2

Description of the Innovative Activity

To reduce post discharge 30-day readmissions by patients with more complex care needs, a team at the Cleveland Clinic Health System (CCHS) explored home visit staffing models. The CCHS team describes their two-phase process and the structure of the innovation, which are summarized here, in a published study on the innovation.2 For Phase 1, the CCHS team experimented with a model in which patients received home visits from either advanced practice registered nurses (APRNs) or paramedics. This model was not associated with a reduction in 30-day hospital readmissions. Then, in Phase 2, for what became the HRTIC program, the team found promising results with a model in which patients received sequenced home visits from both APRNs and paramedics. The team theorized that patients benefited from the combined skills of each of the provider types: APRNs can prescribe and make medication adjustments, operating as independent practitioners, while paramedics have expertise in acute care and responding to urgent patient requests.

The HRTIC program assessment focused on patients with a CCHS primary care provider (PCP) who CCHS determined were at high risk for readmission by using the CCHS readmission risk scoring tool. A primary care practice registered nurse care coordinator (RNCC) could also refer patients to the program based on a subjective assessment of need for post-discharge home visits.

To calculate a readmission risk score, the CCHS tool weighs patient factors that include prior utilization, discharge disposition, medication, comorbidities, and health literacy.3 CCHS uses the tool to determine the likelihood of readmission within 30 days. If the home visit program is close to capacity, program administrators can adjust the risk-score threshold to a higher score threshold (narrowing the eligibility criteria) for new intakes, to ensure that those patients most in need still receive services.

At the home visits, the APRNs answered questions about medications, corrected medication errors, and evaluated the need for special equipment or home care. Furthermore, APRNs educated the patient and family about management of the patient’s conditions and reviewed the patient’s health goals.

According to the CCHS team, the program relies on a centralized RNCC who provides a link between the patients, their primary care team, and the home visit team. The team believes that the success of the Phase 2 model, as shown in comparatively low 30-day readmission rates, is a result of the frequency/number of home visits and combining the unique skills offered by APRNs with the skills of paramedics. The team says that the program should operate as an extension of a patient’s primary care providers, with clear communication between all providers and a consistent course of treatment.

Context of the Innovation

Roughly 14% of all patients and 17% of Medicare patients that are discharged from a U.S. hospital are readmitted in less than 30 days.6

Unplanned and unnecessary readmissions have received increasing attention from payers, and hospitals currently face fines for high 30-day readmission rates.7 Additionally, a 2017 study found that medical costs from hospital readmissions were higher than those from initial admissions for about two-thirds of common diagnoses; the average readmission cost for any diagnosis in 2016 was $14,400.5 Readmissions also exacerbate a widespread strain on inpatient hospital capacity.8

In general, home visits after hospital discharge have shown promise in addressing the problem of preventable readmissions.3 Healthcare payers and providers are studying different home visit and telehealth models to reduce readmissions in the months after discharge and to help keep inpatient beds available.3

Results

In their study on the HRTIC program, the CCHS team describes the results of two phases of the study and their qualitative finings.2 In Phase 1, the home visits program offered patients three home visits by a paramedic or an APRN. Program staff set up treatment groups according to geographic region to make travel distances shorter for the home visit teams. In this phase, half of referred patients accepted the home visits, and the 101 home visit patients showed no differences in readmissions, emergency department visits, or death at 30, 90, and 180 days relative to the nontreatment comparison group.

In Phase 2, 42% of patients referred to the program opted to participate. The program offered them four home visits. The 157 patients who received home visits in Phase 2 had fewer 30-day readmissions than the nontreatment comparison group (19.1% vs. 28.7%) and no differences in other outcomes. Compared with patients who declined participation in the home visit program, those who participated had lower odds of 30-day readmission.

Interviews with 44 participating patients and providers highlighted lack of patient understanding about medications as a common issue after hospital discharge. Additional issues emerging from the data included gaps in patient knowledge after discharge, patient medical complexity, and the social context or lack of patient support. Patients and providers spoke about the importance of the home visits as a means for engaging with patients, many of whom lack social support. Patients noted that the reassurance provided by the home visit providers was valuable.

Planning and Development Process

For the pre-implementation planning phase, the CCHS team note that facility efforts should focus on

  • Ensuring necessary staffing to schedule and complete home visits,
  • Establishing communication channels that allow for flexibility,
  • Developing home visit documentation templates,
  • Training referral and home visit staff, and
  • Understanding that other home visit programs also may be serving the patients and coordinating accordingly.
Resources Used and Skills Needed

The CCHS team reports that the following resources and skills are needed to implement the HRTIC program:

  • Processes and a tool for identifying the highest risk patients. The innovation used the CCHS readmissions risk calculator, which factors patient information on prior utilization, comorbidities, insurance, and a variable to capture language barrier, poor health literacy, or cognitive impairment.3
  • APRNs and paramedics to make the home visits
  • Infrastructure, including a centralized referral and care coordination system and staffing, a program coordinator, communication channels for coordination between providers, standardized reporting procedures, measures of progress, and methods for data collection
  • A protocol for scheduling home visits. For example, once a patient agrees to participate, the home visit care coordination team should contact them within a few days to schedule an initial visit.
  • Training for referring providers and the care coordination team that addresses strategies for working with patients who are reluctant to participate.
  • Cultural competency and tailoring communication to the patients’ level of health literacy are also crucial skills for the home visit teams in their work with patients.
Funding Sources

CCHS supported the innovation and received no outside funding. Dr. Misra-Hebert received funding from an Agency for Healthcare Research and Quality (AHRQ) grant (Grant No. K08 HS024128 - Impact of a Team-based Approach to Primary Care: A Natural Experiment in Primary Care Redesign) to perform evaluation research on the program. AHRQ had no role in the study design or reporting.

Getting Started with This Innovation

According to the CCHS team, to get started, sites will need to set up infrastructure; secure appropriate staffing; obtain leadership and staff buy-in; compile training tools, protocols, and data collection tools and templates; determine referral criteria and scheduling protocols; establish communication channels; prepare for scheduling challenges, including patient resistance; and ensure that hospital providers understand the referral process and referral criteria.

Sustaining This Innovation

An important lesson emphasized by the CCHS team is that patients may be confused and overwhelmed by their different service providers (e.g., home-based primary care vs. the readmission-prevention team) and their respective purposes. It is therefore important to explain, in a manner that the patient can comprehend, the purpose of the readmission-prevention home visit team.

In addition, the CCHS team emphasizes that program organizers should recognize the medical and social complexity of the patients and be prepared to provide education to the team that explains these complexities. Home visit providers should be prepared to deliver strategies for helping the patient population with their psychosocial challenges that lead to adverse health outcomes. Data collection—including data on outcomes beyond several months—will also help with efforts at improvement and sustainability. The team reported that going through medications and follow-up care in the patients’ homes sometimes helped patients better understand instructions. The amount of information provided at discharge can be overwhelming, the team noted.

It is also important, the team noted, to achieve and maintain fidelity to the HRTIC staffing model of the innovation to sustain it (i.e., APRNs to conduct the initial visit, paramedics to provide subsequent visits, and nurses to coordinate care). The team suspects that the innovation has been successful in part because the nurse care coordinators and the APRNs provide coordination with the PCP, and the program also works in collaboration with other CCHS home visit programs, where paramedics are available to respond with little notice when a patient wants or needs a home visit.

The team also reported that the following actions are crucial elements for a successful intervention and for sustaining the innovation:

  • Making early or predischarge contact with the patient about the services as well as checking in with the patient in the first five to seven days
  • Explaining the program and the roles of the home visit team to the patient. It can be a challenge to get patients to agree to the program; they may have other home visit services, which can cause confusion.
  • Having the flexibility to change the eligibility criteria, which has allowed the program to adjust to a higher patient census
  • Having one telephone number for scheduling and dispatch so that patients have a single number to call when needed

Because the improvement in readmission rates was not sustained once the visits stopped, the team feels that the number and frequency of home visits may be the key factor to reducing readmission. If resources permit, the team believes that home visits should continue past 30 days.

References/Related Articles

Bailey MK, Weiss AJ, Barrett ML, Jiang, HJ. Characteristics of 30-Day All-Cause Hospital Readmissions, 2010–2016. Agency for Healthcare Research and Quality, US Dept of Health and Human Services; 2019. Statistical Brief #248. February 2019. Accessed February 22, 2022. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb248-Hospital-Readmissions-2010-2016.jsp

Fraze TK, Beidler LB, Briggs ADM, Colla CH. “Eyes in the home”: ACOs use home visits to improve care management, identify needs, and reduce hospital use. Health Aff. 2019;38(6):1021-1027.

Jackson C, Kasper EW, Williams C, DuBard CA. Incremental benefit of a home visit following discharge for patients with multiple chronic conditions receiving transitional care. Popul Health Manag. 2016;19(3):163-170. doi:10.1089/pop.2015.0074

McWilliams A, Roberge J, Anderson WE, et al. Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a pragmatic randomized controlled trial. J Gen Intern Med. 2019;34(1):58-64. doi:10.1007/s11606-018-4617-1. Epub 2018 Aug 14. PMID: 30109585; PMCID: PMC6318199.

Misra-Hebert AD, Rothberg MB, Fox J, et al. Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission. Healthc (Amst). 2021;9(1):100518. doi:10.1016/j.hjdsi.2020.100518

Misra-Hebert AD, Felix C, Milinovich A, et al. Implementation Experience with a 30-Day Hospital Readmission Risk Score in a Large, Integrated Health System: A Retrospective Study [published online ahead of print, 2022 Feb 7]. J Gen Intern Med. 2022;1-8. doi:10.1007/s11606-021-07277-4

Resources and tools to improve discharge and transitions of care and reduce readmissions. Agency for Healthcare Research and Quality. December 2012. Updated June 2020. Accessed February 22, 2022. https://www.ahrq.gov/patient-safety/resources/improve-discharge/index.html

Footnotes
  1. Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-Day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095-1107. doi:10.1001/jamainternmed.2014.1608
  2. Misra-Hebert AD, Rothberg MB, Fox J, et al. Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission. Healthc (Amst). 2021;9(1):100518. doi:10.1016/j.hjdsi.2020.100518
  3. Misra-Hebert AD, Felix C, Milinovich A, et al. Implementation Experience with a 30-Day Hospital Readmission Risk Score in a Large, Integrated Health System: A Retrospective Study [published online ahead of print, 2022 Feb 7]. J Gen Intern Med. 2022;1-8. doi:10.1007/s11606-021-07277-4
  4. Ruiz S, Snyder LP, Rotondo C, Cross-Barnet C, Colligan EM, Giuriceo K. Innovative home visit models associated with reductions in costs, hospitalizations, and emergency department use. Health Aff (Millwood). 2017;36(3):425-432. doi:10.1377/hlthaff.2016.1305
  5. Weiss AJ (IBM Watson Health), Jiang HJ (AHRQ). Overview of Clinical Conditions with Frequent and Costly Hospital Readmissions by Payer, 2018. HCUP Statistical Brief #278. July 2021. Agency for Healthcare Research and Quality, Rockville, MD www.hcup-us.ahrq.gov/reports/statbriefs/sb278-Conditions-Frequent-Readmissions-By-Payer-2018.pdf.
  6. Bailey MK, Weiss AJ, Barrett ML, Jiang, HJ. Characteristics of 30-Day All-Cause Hospital Readmissions, 2010–2016. Agency for Healthcare Research and Quality, US Dept of Health and Human Services; 2019. Statistical Brief #248. February 2019. Accessed February 22, 2022. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb248-Hospital-Readmissions-2010-2016.jsp
  7. Rewa OG, Stelfox HT, Ingolfsson A, et al. Indicators of intensive care unit capacity strain: a systematic review. Crit Care. 2018;22(1):86. Published March 27, 2018. doi:10.1186/s13054-018-1975-3

FYI: You may notice that the PSNet Innovations Exchange has recently been updated (April 2022) to remove the evidence rating section. For more information or questions, please email psnetsupport@ahrq.hhs.gov.

The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter or developer of the innovation.
Contact the Innovator

Anita D. Misra-Hebert, misraa@ccf.org  (Innovation Evaluator)