Blue Shield of California’s advanced clinical model, called the Core 4, focuses on four critical components of an integrated and optimized delivery system:
- Advanced facility care
- Care management and coordination
- High-risk clinics
- Home care
This fourth of four blogs highlights the successful home health care program at Axminster/Providence Medical Associates, under the direction of Shreeti Patel, MD. We have previously highlighted advanced facility care, care management and coordination, and high-risk clinics.
By Shreeti Patel, M.D., Axminster/PMA Medical Director, Inpatient UM/THCP & Jessica Auzenne-Harris, Axminster/PMA Nurse Practitioner
Willie David Brown is a 75-year-old male who was hospitalized twice this year due to complications from heart failure and kidney failure. When he returned home, his recovery was a challenge. He felt overwhelmed caring for his sister-in-law. Due to his progressive kidney failure, he was becoming forgetful and having trouble seeing. Inadvertently, he was taking double the prescribed dose of his medications for heart and kidney failure.
Fortunately for Mr. Brown, he is a Blue Shield of California member who has access to a home care program made available through Blue Shield’s accountable care organization (ACO) collaboration with Axminster/PMA.
Returning home from the hospital is a complex time for both patients and their families. Patients typically remember and understand less than 50 percent of what is explained to them in the hospital. The transition from hospital to home is one of many gaps in the medical system. A multi-disciplinary team is essential to support patients during this time.
Recognizing this critical need among patients going home, Axminster/PMA and Blue Shield launched our transitional home care program in the fall of 2017. Our nurse practitioner visits members at home. She performs a comprehensive assessment of the patient’s medical and social needs in and around the house. Members of the care team, which includes an internal medicine physician, nurse practitioner, social worker, complex case manager, and pharmacist, then discuss the case and formulate an individualized care plan. The plan incorporates medical and nursing care, patient and family education, as well as coordination of care with specialists and community resources (including telebehavioral health through Magellan, Cal Fresh, Meals on Wheels, National Alzheimer’s Association, and community cardiovascular classes).
Upon hospital discharge, the goal is to have comprehensive care in place so the patient can maintain independence and a vibrant quality of life, like Mr. Brown. Including the patient and family as part of the healthcare team is essential. Shifting from patient education to patient engagement is a critical component of this program’s success.
Before becoming enrolled in the transitional home care program, Mr. Brown often missed his scheduled heart, kidney and vascular surgeon appointments. After enrollment into the program, the nurse practitioner made certain Mr. Brown was evaluated by a vascular and kidney specialist for access to dialysis. She removed discontinued and expired medications from his home. She educated him on how to use a daily pill box. Recognizing his poor vision, she wrote medication directions in large print and obtained easy-open caps for the bottles.
After hospital discharge, approximately 1 in 5 patients experience complications such as adverse drug events. Nearly 100,000 elderly patients are hospitalized every year due to adverse drug reactions. Knowing this, these simple-yet significant-changes helped Mr. Brown improve his overall health and maintain his vitality.