Tanya Stewart, MD FAAHPM

It’s late afternoon when you receive a call from a home health nurse about a patient you’ve known for 12 years. Mr. Jones is 70 years old with multiple chronic medical conditions contributing to four hospitalizations in six months. He was referred to home health two weeks ago as part of his hospital discharge plan for heart failure management. The home health nurse reports he hasn’t been eating well for the past two days, is unable to walk across the room without stopping to rest and is becoming more confused. His care needs are escalating, and his 76 year old wife is no longer able to manage his needs. He was referred to hospice many times in the past and each time refused. At the last hospitalization he agreed to DNR code status with limited interventions, and his primary goal is to remain as functional as possible. The home health nurse requests guidance on how to proceed.

In the traditional medical system, Mr. Jones would most likely be sent to the emergency room and again admitted to the hospital. I propose there’s a better, more innovative option that breaks this cycle:

It’s late afternoon when you receive a call from an Optum nurse practitioner (NP) to inform you that Mr. Jones has been referred to CarePlus by his health plan as part of his hospital discharge plan. The NP visits Mr. Jones in his home the day after hospital discharge and talks with him and his wife to gauge their understanding of what happened in the hospital and next steps. The NP also completes a medication reconciliation, examines Mr. Jones and reviews his goals of care. At the close of the initial visit, the Optum NP gives the patient and caregiver his/her cell phone number and specific instructions to call if they have any questions or if certain symptoms arise. After the visit, care is coordinated with the local home health team and the Optum NP’s note is faxed to your office. Four days later, the Mrs. Jones calls the NP – she is concerned about increasing incontinence. The NP arranges for a chem7, BNP and urinalysis which are drawn by the home health nurse that day. The Optum NP reassures the Joneses and schedules a home visit for the following day.

At the following day’s visit, the Optum NP notices the Mr. Jones has increased LE edema, elevated JVP, difficulty speaking in complete sentences and increased lethargy. The urinalysis returned within normal limits. The chemistry panel is unchanged from discharge but BNP is 682 pg/ml. Mrs. Jones confirms he is taking the medications as directed from the last visit.

When the NP asks about diet, Mrs. Jones says they eat a healthy diet consisting of mostly soup and vegetables. With her permission, the Optum NP looks in the fridge and cupboards and notices the patient only has high sodium canned soup and vegetables. No fresh produce is found in the house. After extensive dietary counseling and coordination with a local meals on wheels program, the NP orders a diuretic increase, home oxygen, follow-up labs and arranges daily home health nursing visits for one week. The Optum NP closes the visit with a review of Mr. Jones’ advanced care plan. The Optum NP calls your office to provide an update, and a note is faxed the next day.

Over the next few days, the home health nurse calls the Optum NP several times reporting Mr. Jones seems improved. A potassium supplement is added to address low levels on a lab draw, and the NP requests the home health nurse reinforce with both patient and caregiver the importance of staying on a low sodium diet.

The following week, the Optum NP receives a distressed call from Mrs. Jones. Her husband is struggling to breathe, is again confused and unable to walk from his bed to bathroom. The NP makes an urgent visit and during the history review, Mrs. Jones admits she had high sodium take-out food delivered to the home the night prior at her husband’s request. After a complete assessment, the Optum NP confirms a diagnosis of heart failure exacerbation caused by dietary indiscretion. She implements a home hospitalization and administers intramuscular Lasix on two consecutive days and draws chem7 and BNP. Throughout the course of the acute event, the Optum NP calls your office to collaborate on the patient’s care and provide real-time updates.

On day three, Mr. Jones’ weight is down, but he is too weak to ambulate or complete any ADLs. His wife is fatigued and had a fall the previous evening when trying to help him to the bedside commode. Although he was adamantly against getting care at a skilled nursing facility (SNF), he agrees this may be necessary so he can gain strength to return home. The Optum NP arranges a direct admission to the neighboring nursing home for skilled care after speaking to the house physician and SNF admission coordinator. The Optum NP sends all notes from the Optum electronic medical record with the patient, calls your office to clarify your desire to follow the patient at the SNF or have the house doctor follow, and communicates the care plan changes with the health plan and home health agency.

During the skilled stay, the Optum NP sees Mr. Jones regularly, along with the attending physician. During one of the visits, the Optum NP reviews the goals of care. Mr. Jones recognizes he is tired of being so sick and is not living the quality of life he imagined. He requests his Physician Order for Life Sustaining Treatment be changed to comfort measures and hospitalize only if symptoms cannot be controlled at home. The Optum NP offers hospice, but he and wife again decline.

After regaining strength and the ability to complete his ADLs, Mr. Jones returns home. Over the course of the next six months he is treated by the Optum NP for a urinary infection, community acquired pneumonia and cellulitis. He does not have any additional hospitalizations during this time. During the holidays the Jones’ daughter visits from out of state for the first time in two years. She raises concerns about her father’s decreased strength, weight loss, confusion and instability with transfers. The Optum NP holds a family meeting and a decision is made for Mr. Jones to enroll in a hospice program.

As you can see, CarePlus goes beyond traditional care management programs. Providers deliver hands-on care to members at home and, if necessary, treat them. By doing so, CarePlus helps individuals avoid unnecessary hospitalizations and emergency room visits, reducing costs and improving quality. Throughout the relationship, CarePlus coordinates and delivers compassionate, hands-on care to individuals while providing ongoing care coordination with their primary care provider.

Do you serve in a more traditional system and see how such a model could benefit your patients? Do you work in a program like CarePlus, but with a different approach that’s achieving similar results?

Dr. Stewart works for Complex Population Management in Oregon and as the medical director for Community Home Health and Hospice in Longview, WA.

This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.