Pa. hospital team makes house calls to patients
Allegheny Valley Hospital established a team of doctors, nurses and paramedics to visit high-risk patients to help reduce readmission rates
By Luis Fábregas
The Pittsburgh Tribune-Review
GREENSBURG, Pa. — The doctor sat in Valerie Robinson's apartment and marveled at the number of pill bottles she kept in a zippered bag.
“Holy schmoley, girl!” Dr. Rick Fogle said as he sorted through the medications in Robinson's Harrison high-rise.
Checking the drugs against a list, Fogle concluded that more than half were not part of her official medical record. Within two hours, he found that Robinson's doctor had moved offices and she needed a new doctor.
Without this rare home visit, Robinson, 65, likely would have ended up hospitalized, Fogle said. To avoid this, hospitals target patients such as Robinson and send doctors to their homes, hoping to prevent readmissions.
“We go outside the walls of the hospital for early recognition of symptoms going bad,” said Lori Shotts, a registered nurse who is part of a high-risk care team that tracks patients at risk for readmission to Allegheny Valley Hospital. “We want to keep the patient at home where they want to be.”
The hospital's approach is fueled partly by the government's goal to curb readmissions, which cost an estimated $12 billion in Medicare spending. Three-quarters of readmissions are preventable, according to an analysis of claims data by the Medicare Payment Advisory Commission.
The Centers for Medicare & Medicaid Services in 2012 began imposing fines on hospitals that readmit too many patients within a month of discharge. Records show Allegheny Valley in the past two years received among the steepest fines for hospitals in Western Pennsylvania — 1 percent of its Medicare reimbursement.
Penalties nationwide have averaged about $127,000 per hospital every year.
Experts say the fines have pushed hospitals to send workers to patients' homes, where they might learn some people can't get a handle on their health. The task falls primarily on nurses; it's unusual for doctors to visit homes, said Dr. Karen Joynt, an instructor at Harvard University School of Public Health who studies readmissions.
“Some patients are so complex, it makes a ton of sense for a physician to visit those homes,” Joynt said.
Fogle, who began working for Allegheny Health Network in June, said most patients at risk for readmission are those who have trouble with medications — taking the wrong dosage, or trying to juggle multiple drugs prescribed by doctors who did not communicate with each other.
“It's always the meds. It's our society. Everybody thinks a pill will make them better. If one pill won't do it, they want another one. It's a pharmaceutical nation,” he said.
Who gets home visits
The impetus to address readmissions at Allegheny Valley came in March 2012 when administrators noted just over 19 percent of patients were returning within a month of discharge.
They established the high-risk care team — nurses, social workers and paramedics — to meet daily and review details of recently discharged patients who they suspected might return. Most such patients are elderly with diabetes, congestive heart failure or other chronic conditions.
They do not follow specific guidelines when deciding who should get a home visit.
“It's just a feeling,” said Fogle, 61, who was an Army physician in Afghanistan and is a brigade surgeon for the Pennsylvania National Guard. “If it looks like every 21 days that patient is coming back, we figure, let's hit him on Day 19 and stop him from coming back in.”
Robinson fit the bill. The former mental health counselor is diabetic and was hospitalized more than 10 times in a six-month period — for symptoms such as chest pain, shortness of breath, back pain and headaches.
When Fogle asked to look at her medications, she gave him a container with 16 pill bottles. As he checked them, she produced two plastic bins filled with medicines, ointments, vitamins and medical supplies.
“I never throw my bottles out,” said Robinson, who sat on a bed in her living room, near the kitchen and a large flat-screen TV.
Fogle and Shotts discarded about a dozen of Robinson's pills bottles. Shotts pricked Robinson's finger to test her blood in a glucometer. Later she listened to her lungs.
When Robinson told Fogle that her doctor had moved to Bloomfield, he promised to make an appointment for her with another doctor.
“It's right here, right around the corner. You can power-chair over there,” he joked. “Is that a deal? Keep you out of the hospital?”
She nodded and smiled. And having a physician check on her at home should help her stay healthy, she said.
“I get confused about the medicines,” she said.
Expanding the practice
Officials at Allegheny Health Network consider the program successful enough to try it at other hospitals.
Readmission rates at Allegheny Valley dropped to 11.8 percent in May, the lowest since officials recorded the 19.2 percent readmission rate in March 2012.
UPMC Health Plan started a similar program about a month ago that is run by doctors from an internal medicine practice at UPMC Montefiore in Oakland. The program has enrolled 20 patients, said Dr. Jodie Bryk, who leads the program with Dr. Gary Fischer.
“We're trying to get out of the practice of you coming to the hospital to be seen,” Bryk said. “Patients are better off if they stay at home.”
©2014 The Pittsburgh Tribune-Review (Greensburg, Pa.)