Medical Visits Returning to Patients Home
Patient-Centered Compassionate Care
Overview
Effectively servicing patients who are home-bound has historically been a challenge for caregivers. While many home care agencies offer nursing and some advance sub-acute level of care, the need for mid-level and MD care has seen a rise in the past year. While this is also driven by post-pandemic challenges, the results have been very favorable. Likewise, this is another tremendous revenue generating opportunity for practices who are willing to be flexible. Historically physicians would make rounds at Hospitals, Urgent Care Centers, Nursing Homes, and Assisted Living locations. However, chronically ill patients staying at home is on the rise and so medical groups can benefit from expanding these “rounds” to a patient’s home.
Benefits Of the Program
Meeting the demands of chronically ill patients can be extensive and require a diversified specialty approach. The origins of these patients can be vast as well. As an example:
Long-Term Primary Care
These are typically home bound patients with many restrictions. Support may include traditional ambulatory care provided by home care services, but many require routine examinations by a mid-level provider or an MD.
- Whole spectrum of primary care
- May require specialty care as well
- Medication management a must including writing Rx and refill management
- In-home diagnostic services as well including lab, blood testing, EKG’s, x-rays, sonograms, and ultrasound
- Coordination of medical care for other support services including DME, skilled nursing and home health
Transitional Care
Patients discharged from a hospital or even long-term care facilities require follow up visits to ensure treatment plan compliance and adoption.
- Focused intervention targeting patients for 30 days following discharge to reduce hospital readmission and speed patient recovery
- Ensure patients adhere to discharge plans, including medication compliance and post-discharge follow up with PCP
- Coordination of support services for additional home care needs, such as skilled nursing, physical and occupational therapy, DME and medical supplies
- Even the coordination of Infusion service at home for patients
Specialty Care
Wound care and podiatry patients require diligent regular visits to ensure a quality recovery.
Patient care is a team effort. Successful outcomes are predicated on efficient communication and coordination across care teams, compliance with medication, and identifying early warning signs to preempt problems and avoiding ER or re-hospitalization.
Program Overview
Here is an example of how an effective House Calls Clinical Department can operate. Clinical department consist of:
- Medical Director
- Chief Clinical Supervisor
- Providers (MDs, NPs, PAs, RNs): Over 100 Providers
- Clinical Swat Team
- Telemedicine
- Quality Improvement and Compliance
- Risk Management Committee
- Chronic Care Management (CCM)
- Clinical Assistants: CAs 52
- Critical Labs/DIs Coordinator
- Clinical Call Center (can be outsourced to third party)
Clinical support includes a comprehensive platform enabling their care team to function at a high level:
- Provide educational tools to clinical staff:
- Clinical Protocols, CMEs, eLearning, Support from specialists
- Chronic Care Management
- Quality and Compliance
- Provides score card
- Internal chart Auditing
- Critical Labs/DI monitoring
- Addressing critical labs/DI within 3 hours
- Hierarchical Categorical Condition (HCC) Score Optimization
- Quality Measures (HEDIS, PQRS, COA etc.)
- Clinical Call Center along with Provider On-Call services after hours, weekends and holidays
In summary, offering House Call services as an extension of your practice is a natural progression many groups are moving toward. This is a cost-effective approach for patients and expands the revenue opportunity for practices.
Call to Action
We want to hear from you to discuss how we can help to protect the financial stability of your medical group or health system and enhance the relationship with your patients.
