Burt and Ardis Ramaker were pleased with their experience in the Care Transitions Program, and thankful it helped Burt to recover at home.

When Burt Ramaker left the hospital following a successful hip replacement, he didn’t plan to go back any time soon. He and his wife Ardis imagined they would spend time at a skilled nursing facility to get him back on his feet, and then they’d be back at their waterfront cabin.

Instead, they found themselves in and out of the doctor’s office and the emergency room. Burt was on his way to being readmitted to the hospital. Patients of all ages with multiple chronic conditions are more likely than others to be readmitted to the hospital soon after discharge. However, this risk is especially high for older patients like Burt, especially if they have several chronic health conditions.

But if patients receive the right care, at the right time, and the right place, many of these readmissions could be prevented. And that was why Burt was identified for the program and his doctor recommended Burt sign up for a care management effort called the Care Transitions Program.

Newfangled house calls

At the Rochester, Minnesota, campus, the Care Transitions Program, part of Mayo Clinic's Department of Employee and Community Health, features a new kind of house call. The program offers services to older adults with complex medical needs when they leave the hospital or skilled nursing facility. The patient-centric program features a home visit from a nurse practitioner within five days of discharge. In addition, patients receive follow-up phone calls from their care team, access to a nurse line for urgent questions or concerns, and additional house calls by the nurse practitioner when necessary.

Supervised by geriatricians – physicians specializing in elder care – the program provides individualized care and support for patients and their families.

Brenda Danielson is an advanced practice registered nurse and certified nurse practitioner at Mayo Clinic in Rochester, Minnesota.

Shortly after Burt enrolled, he and Ardis were visited by Brenda Danielson, a nurse practitioner in the program. She examined Burt, and they sat down to discuss what to do about his newly diagnosed heart failure and severe fluid build-up. Danielson wrote notes for Ardis and Burt, detailing his care plan and what had been discussed.

The Ramakers say Danielson visited monthly for several months – replacing what had been approximately weekly visits to the clinic or emergency room.

“It was great,” says Burt. “It saved me going up to the hospital a number of times, and I thought she [Danielson] was great!” He was unhappy at the nursing facility, he says, and “this program allowed me to come home.”

Danielson and others like her work with patients in the program to provide:

• Medication reconciliation – both reducing use of high-risk medications, and lessening medication ‘misadventures’
• Home safety assessments
• Community resource referrals
• Continued care for the health problem that led to the patient’s hospitalization, as well as the patient’s chronic health conditions

Burt Ramaker credits the Care Transitions Program as the reason he can step out onto his patio and fill the bird feeder, and engage in a host of other life activities.

The nurse practitioners also work with the patient to determine his or her goals for care, as well as to determine sources of social and other types of support. Together they develop strategies for:

• Early recognition and management of health issues (before they necessitate an emergency department visit and potential readmission)
• Patient self-management of chronic diseases
• Advanced care planning

In Burt and Ardis’s case, Danielson also helped Ardis to understand and fill out insurance paperwork.

“I felt so comfortable asking for help,” says Ardis, “[for] any questions I had.”

Ardis says having the nurse practitioner visit, talk with them and leave detailed notes, helped her. “Knowing that I was doing it right,” she says was a comfort. And Burt got better – which they both say was their biggest benefit.

Patients like them, but do these house calls have other value?

“Bringing care to the patient is not only patient-centered, but can be beneficial to the institution,” says Rozalina McCoy, M.D., a primary care physician at Mayo Clinic who is also part of the Care Transitions Program team. But what seems like a good idea needs to be proven to add value. So the physician-researchers put it to the test.

They report that the program nearly halves unplanned readmissions within 30 days of discharge. Their research also shows better quality of life, fewer visits to the emergency department, decreased risk of death, and other potential benefits, including lower overall care costs for individuals and the health care system.

However, these observations have been broad, and the team is digging in further, to determine ways to predict and prevent readmission for as many people as possible. In addition, some types of readmission really aren’t preventable. Understanding these nuances will help Mayo Clinic provide better care for patients, and further refine the Care Transitions Program and other programs like it.

The latest piece of evidence

Patients enrolled in the program were much less likely to be readmitted than patients receiving usual care.

In their most recent study, led by Dr. McCoy, the researchers examined the program to determine its ability to reduce potentially preventable and non-preventable 30-day readmissions.

Using both a commercially available algorithm and another from the Centers for Medicare and Medicaid Services, Dr. McCoy’s team first determined which readmissions were potentially preventable. Some readmissions, she says, are either planned, or impossible to avoid, regardless of intervention.

Their study group included 365 enrollees in the Mayo Clinic Care Transitions Program, matched to a control group of patients who met enrollment criteria for, but were not enrolled, in the program.

In addition to being a primary care physician, Rozalina McCoy, M.D., is an endocrinologist, and conducts health sciences research at Mayo Clinic.

Overall, they report, patients enrolled in the program were much less likely to be readmitted than patients receiving usual care. However, when examining reasons for readmission, the team found that about two-thirds of all readmissions may still be preventable, both among patients enrolled in the Care Transitions Program and among those not enrolled. So even though the Care Transitions Program prevented more than 4 out of 10 readmissions, there is still a lot of room for further research into specific interventions for program participants.

In addition, readmissions for all causes – not just those related to the reason for the patients’ first hospital stay – seemed to be prevented, suggesting that providing intensive home-based care to high-risk patients may be an effective strategy in general, not just after a hospital admission.

“We believe timely home visits and a coordinated care program can prevent all types of hospitalizations, ED [emergency department] visits, and hospital readmissions,” says Dr. McCoy. “Perhaps not ‘all’ hospitalizations and readmissions, but certainly as we refine our ability to identify patients who are likely to have events or poor health outcomes, and then provide intensive, individualized, home-based transitional care, we expect the numbers to continue to decrease.”

Decreasing hospitalizations is great, of course, for patients and health care in general. But on an individual level, for Burt and Ardis, it means more time together, and more time fishing at the cabin.

###

Dr. McCoy is a Kern Health Care Delivery Scholar in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, which focuses on improving health care outcomes, lowering costs and enhancing patient experience. The center collaborates with Employee and Community Health to find ways to improve health and health care delivery in the local community.

Tags: care transitions, Center for the Science of Health Care Delivery, Findings, Innovations, Rozalina McCoy