Award-Winning Home Visits Program:
Payoffs from Targeting Complex Patients
The philosophy behind Community Care of North Carolina's award-winning care transition management program is simple: transitional care works better for some than others.
Before investing in home visits, pharmacist involvement and early outpatient follow-up, healthcare organizations should discern the patients most likely to benefit from these resource-intensive interventions as well as those who won't, advised Carlos Jackson, PhD., CCNC director of program evaluation.
"Transitional care often becomes a one-size-fits-all intervention, where providers feel they have to do the same thing for everybody coming out of the hospital," Jackson noted during Measuring and Evaluating the Impact of Home Visits for Clinically Complex Patients, a March 2016 webinar now available for replay.
In case you missed this webinar, you still have a chance to watch this highly-rated program.
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In outlining the CCNC approach, Jackson recommends transitional care be targeted toward patients with multiple, chronic or catastrophic conditions to optimize an organization's return on investment.
His organization's dexterity in determining and managing a priority population for transitional care (TC) helped to earn CCNC the inaugural Hearst Health Prize for Population Health earlier this year. With a presence in all one hundred North Carolina counties, CCNC manages 1.5 million Medicaid beneficiaries, among other populations.
Statistically, CCNC determined that only a quarter of its Medicaid discharges were likely to meaningfully benefit from transitional care, and that even within that priority population, only a smaller segment would benefit meaningfully from resource-heavy interventions.
Of all face-to-face encounters with CCNC priority patients, include hospital bedside and office visits, appropriately targeted home visits reduced this population's likelihood of being readmitted to the hospital most significantly, noted Jackson.
"Of course, you can't do a home visit with everybody. If you want a positive return on investment to cover the cost of the home visit, you need to focus on the highest risk patients."
Modeled on the Coleman Transitions Intervention Model®, the eight-year-old CCNC program has elements common to many transitional care initiatives—data analytics, embedded care management, telephonic and face-to-face follow-up. But CCNC has reexamined some traditional transitional care tenets, such as the notion that this type of care is necessary for all.
"Actually, most patients don't benefit," Jackson noted. "Lower risk patients don't benefit. The evidence for benefit is much weaker if you are not one of these high risk, multiple chronic patients."
His organization has also widened its transitional care lens beyond a focus on reducing readmissions. "It's sometimes myopic to focus on just serving the 30-day readmissions," Jackson continued. "If you can deliver good transitional care, you can keep them out of the hospital for a very long time and affect their outcomes way into the future."
The CCNC transitional care approach for North Carolina Medicaid beneficiaries with multiple chronic conditions resulted in more than 2,200 fewer readmissions and 8,000 fewer inpatient admissions in 2014 as compared to 2008, Jackson concluded.
You can "attend" this program right in your office and learn about CCNC's home visits program. It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.
You'll get to listen to the question and answer session to hear: how the home visits are financed; how the home visit is introduced to the patient; details on the assessement tool to determine readmission risk; and how program success is measured.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Measuring and Evaluating the Impact of Home Visits for Clinically Complex Patients, please visit:
P.S. -- You may also be interested in these home visit resources: