Keeping Patients Out of Hospitals: A Private-Sector Approach to Health Reform

[chuckster, ADN, BSN, RN, EMT-B]

Interesting article from the month's Atlantic:Keeping Patients Out of Hospitals: A Private-Sector Approach to Health Reform By Adam Wolfberg

Hospitalization alone costs $3,000 to $4,000 per day. By aligning incentives, a California practice is thriving, saving money, and keeping people in their homes and community.

Link to complete text of article: http://www.theatlantic.com/health/archive/2013/02/keeping-patients-out-of-hospitals-a-private-sector-approach-to-health-reform/272916/

What I find puzzling about the article is that much of the narrative about the care provided by the physician profiled is well within the scope of practice (generally speaking) of an RN. The model would make more sense with RN's providing more of the in-home treatment and examination mentioned in the narrative as being done by an MD. Obviously, some or even many patients may need medical care that only a physician can provide, but the RN would certainly recognize this and schedule a follow-up visit by the MD. This would likely save even more money, not to mention provide better and more individualized care for the patients.

Perhaps I'm missing something though.

[tewdles, RN]

I tend to agree with you, Chuckster.

Professional nurse case management of patients in the community would be less expensive and at least as effective.

Patients shouldn't be interacting with RNs primarily in the acute care setting if we want to improve our health behaviors and outcomes.

[Mike A. Fungin RN]

"Elderly account for 70% of healthcare spending and 80% of that is in the final month of care. HealthCare Partners is somehow getting their elderly population to choose home and probably hospice at rates double the national average which is due to either "death panel" decision making or some hefty persuasion processes.Everything else that they do, although nice and all, hardly moves the needle compared to the above. This is probably subsidizing everything else that they do."

[BrandonLPN, LPN]

A system with an increased focus on prevention and a larger role for the community health RN is not necessarily "private sector" as opposed to "government funded". This sort of set up is exactly what happens in Japan and many European countries. And no one would call those systems "private sector".

[NRSKarenRN, BSN, RN]

This doctor is practicing as a "House Call Doctor". I work with four physician groups and one NP practice like this in Philadelphia area. Clients are all "home bound"-meaning rarely leave home, except by ambulance trip to hospital for assessment, as too difficult to leave house. Physician visits q 1-3 months. Some practices have RN/ Social Work Case Managers who manage getting meds filled, arrange for durable medical equipment, arrange for Office of Aging serivces for assitance with ADL's, help with financial arrangements for patients without insurance/unable to pay for meds.

Home Health Agency is contacted and manages clients with acute illnesses CHF/COPD/DM, New wounds/ Chronic slow healing ulcers or need medication managment, monthly foley catheter and tracheostomy changes. Agency has had some clients receiving Skilled Nursing since 2008 without hospitalization. National rate of rehospitalization is 27%. Our agency started Telehealth program which has expanded from CHF clients to those with multiple hospitalizations, has reduced rehospitaliation rate to ~6%. Therapy is called in periodically whenever functional decline occurs to improve activities of daily living with ambulation, bathing/grooming.

Mercy Home Health Telemedicine Program wins Gold Patient Safety Award

I often inform families of availabililty of home visit practices as most are unaware. Our health system has started several physician practices as "Medical Homes" with RN care coordinator for telephonic follow-up patients post hospitalization, missed physicians visits, need for followup lab work to manage PT/INR or diabetic management, arrange for long term care (LTC) services: home care, office of aging services, SNF placement, etc.

The use of Nurse Practitioners in this role will expand if we can get MEDICARE to approve NP/ CNS/PA's to sign for home care plan of care and equal payment for Medicaid coverage.

ANA supporting these 112th Congress legislative efforts

Home Health: Plan of Care Designation

Medicaid Coverage of Advanced Practice Nursing

Barriers to the Practice of Advanced Practice Registered Nurses

All of these efforts have NURSING at the forefront of healthcare.

[Katie82, RN]

You have hit the nail on the head here. I worked for a Case Management program in the south. We were funded by the state to work with Medicaid and Medicare recipients to manage care with a focus on preventing unnecessary admissions and readmissions. We saved the state MILLIONS in costs. This model will be a key component in health care reform.