Mobile teams fill the gap between the hospital and the community
Clinicians visit at-risk patients at home after discharge
Executive Summary
A clinical team from The Valley Hospital in Ridgewood, NJ, visits at-risk patients at home after discharge if the patients don’t qualify for or refuse home health services.
• A mobile team that includes a paramedic, a critical care nurse, and an emergency medical technician visits patients who have been referred by the case managers after a risk assessment.
• The team performs a comprehensive assessment of the patients and their home situations and reinforces the discharge teaching they received in the hospital.
• In most cases, the team makes only one visit but will return if the patient still needs support.
When patients with cardiopulmonary issues either don’t qualify for home health services or refuse them, a clinical team from The Valley Hospital in Ridgewood, NJ, visits them at home shortly after discharge and performs a comprehensive assessment of the patients and their home situations, and reinforces the discharge teaching.
The Mobile Integrated Healthcare Program is part of a bigger project to prevent readmissions by filling the gaps between the inpatient setting and the community, says Lafe Bush, a paramedic and the hospital’s director of emergency services. The mobile teams include a paramedic, a critical care nurse, and an emergency medical technician.
“We believe that no patient should go home without support. Patients with cardiopulmonary disease, especially heart failure and chronic obstructive pulmonary disease, are particularly susceptible to rehospitalization, especially during the transitional period after they first arrive home. This program is another way of getting a home visit for these patients at a time when they are most vulnerable,” Bush says.
The program, which began in August 2014, is a collaboration between Valley’s Department of Emergency Services and Valley Home Care. The program initially targeted heart failure patients, but has been expanded to include patients who have undergone transcatheter aortic valve replacement.
When patients come into the hospital, the case manager assesses them and stratifies them as to risk for readmission, according to Robin Giordano, RN, NP, supervisor of Valley’s Outpatient Transitional Care Program. “If the discharge plan calls for home care and at-risk patients don’t meet the criteria or they refuse home care, we call in the mobile team,” she says.
Many of the patients in the program are elderly, but the team sees younger patients as well, Bush says. “It doesn’t matter how old or young they are — if there is a need, we send in the team,” he adds.
When the team visits, they conduct a full assessment of the patient, including a physical exam, and look for safety issues and other problems in the home. If the team uncovers a social issue, such as empty cupboards or the need for assistance with housekeeping, they call in a social worker. If the patient needs help with transportation to their physician visit, they work with the health system’s transportation department to line it up.
The emergency medical technician surveys the home for safety risks, such as how the patient is able to get in and out of the bathtub, and if there are throw rugs or appliance cords that pose a hazard.
The paramedic takes vital signs, performs an EKG, checks the patient’s blood sugar, and works with the nurse on medication reconciliation.
The nurse makes sure that the patients have filled their prescriptions and have follow-up appointments with their primary care providers and reinforces the discharge teaching, educating patients on their treatment plan and how to follow it, Giordano says.
“Sometimes it’s something as simple as getting them a medication box and teaching them to sort their daily medication,” she adds.
Most of the visit involves education, Giordano says. “We know that patients retain only a small amount of information they receive in the hospital. They can absorb the information better when they are at home and comfortable rather than when they’re in a hospital bed and ready to be discharged,” she says.
Having a healthcare team see the patient’s home situation firsthand is invaluable in helping patients follow their treatment plan and avoid emergency department visits and readmissions, Giordano says.
“People often tell you what they think you want to hear. When the team visits patients at home, they often see a whole different world from what the patients reported to the hospital team,” she says.
In many cases, the mobile team attempts to persuade patients who have refused home health to accept visits from home care nurses.
“The team members take the time to explain what home care is all about. A lot of times, they think it’s around-the-clock service or that someone is coming in to bathe them. We explain that the home care nurse will visit periodically but will not try to take over their lives,” Bush says.
In most cases, the mobile team makes only one visit to the patients’ homes but will come back if they feel the patient needs follow-up.
“The team makes a second visit if they can tell the patient still doesn’t quite understand their discharge plan. We ask if we can come back in two days and check on them again,” he says.
The team has the connections to leverage the resources of the entire Valley Health System as well as community and county resources, Bush says.
In one instance, an elderly man with heart failure the team was visiting weekly called in between visits and said he was having trouble breathing. The team went to the home and administered IV furosemide. They referred him to Valley Health’s outpatient heart failure program and arranged for transportation through the Valley Health transportation system.
“All of the programs at Valley Health work together to take care of the needs of these patients,” Bush says.
A clinical team from The Valley Hospital in Ridgewood, NJ, visits at-risk patients at home after discharge if the patients don’t qualify for or refuse home health services.
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