Tuesday, 23 February 2016 16:32

Good Health at Home

Written by Robert Fortini, PNP, and Irene Zolotorofe, RN, MS, MSN


  Bon Secours Medical Group’s Good Health at Home program is a home-based primary care program that has a unique approach to provide “healthcare without walls” to patients in our community. The program provides comprehensive, interdisciplinary, primary care in the homes of our most vulnerable patients. Their complex medical, social, and behavioral conditions often render standard clinic-based care ineffective.

The program serves two types of populations. The first patient population includes those patients transitioning from a hospital or post-acute setting back into the community. In these cases, an aim of the care is a safe transition back into the community. Care provided is time-limited and focused on stabilizing the patient’s symptoms and chronic conditions. Success is a return of care management responsibility to the patient’s existing primary care provider.

The second population served in the program includes patients with complex, chronic, progressively disabling diseases who require long-term, home-based provider care. This component of the program is designed to serve patients with chronic illnesses who require months and possibly years of care before death. The program is designed to provide primary care, palliative care, rehabilitation, disease management, and coordination of care services. Patients often require assistance with activities of daily living, taking medication, and managing social stressors. This program often serves patients who are isolated; any family caregivers are heavily burdened and often overwhelmed.

The Bon Secours Medical Group home-based primary care team is comprised of an acute-care nurse practitioner (ACNP), physician, embedded RN nurse navigator, dietitian, pharmacist, and mental health provider. All team members work together to care for patients in their homes and improve the likelihood that patients can remain there through the end of life.

Description of at-home Transitions of Care Program

 At the time of discharge from a hospital or post-acute care setting, older patients typically rely heavily on available family and community resources. Older adults have longer hospital stays and more functional decline due to complicated physical and cognitive impairments. The at-home team, led by an ACNP along with an embedded RN nurse navigator, manages these patients in transition. The ACNPs have specialized training in the management of patients with acute, chronic, and palliative medicine. This specialized training allows for a holistic approach to managing patients across the continuum of care. Other care providers support the program as well: clinical pharmacists are available for complex medication management and review, registered dietitians support any concerns of nutrition, social workers address social barriers to care, and RN case managers support the patients at the highest levels of risk in the transitions of care. Behavioral health team members are available on an as-needed basis.

The ACNPs begin their day by rounding in the hospital. They collaborate with the hospitalist team during the discharge process to ensure identification of the main concerns that should be focused on during the transition. It is imperative that the ACNPs review and manage the associated comorbidities in the transitions. They meet with the patients in the hospital and review the purpose of the home visits. After the patients arrive home, the ACNP admits them to the program and manages the care. ACNPs collaborate with patients’ community PCPs; this dialogue allows for the improved transition.  

After the initial evaluation of a patient, bimonthly visits are made until the patient is stable in the home. The ACNPs are available to the patients by phone throughout the process. The RN navigator follows up with the patient on a weekly basis and often will make visits to the home to ensure that the treatment plan is being followed or to determine whether it is in need of refinement. This team approach makes the program successful.

The goals of the ACNP are to eliminate unnecessary readmissions, fill any gaps in care, manage polypharmacy, prevent injuries in the home, stabilize symptoms, and eliminate any barriers to the care of chronic conditions. Most importantly, ACNPs communicate with community providers and hospitalists to improve the outcomes of patients leaving a hospital or post-acute setting. The hospitalist team feels more confident when discharging patients to the ACNP team that care will be managed proactively and readmissions prevented. This confidence allows the hospitalist team to meet appropriate length-of-stay targets.   

Once a patient is stable, the ACNP will transition the patient back to their PCP. If the patient cannot be transitioned back to their PCP and need long-term management in the home, the patient will be transitioned to our nurse-led PCP program.

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Last modified on Tuesday, 23 February 2016 16:39