June 15, 2023

Program keeps close watch on high-risk home health patients

Vanderbilt Home Care Services’ Chronic Disease Management program complements in-person medical visits and traditional home health services with regular telehealth calls from a registered nurse.

Kate Whitley is participating in a free virtual support group at VUMC for those with Long COVID.
Members of the Vanderbilt Home Care Services’ Chronic Disease Management team include, left to right, Kristina Niehoff, PharmD; Candy Probst, RN; Amy Harrison, president of Vanderbilt Home Care Services; and Tara Horr, MD, chief medical advisor for Vanderbilt Home Care Services. (Photo by Susan Urmy)

When 71-year-old Gladean Robinson learned her blood pressure was much higher than normal during a check-in for a primary care medical appointment, she immediately called Candy Probst, RN, for advice on what she should do next.

Probst is the program liaison for Vanderbilt Home Care Services’ Chronic Disease Management (CDM) program, and she and the CDM team began keeping a close eye on Robinson and her health in mid-April.

The CDM program complements in-person medical visits and traditional home health services with regular telehealth calls from a registered nurse. Qualifying conditions include heart failure, chronic obstructive pulmonary disease, diabetes, and pneumonia, as well as post-coronary artery bypass surgery and post-heart attack.

“The increased communication with patients helps provide education on how to monitor chronic conditions, ensures patients have the appropriate medications and supplies to successfully manage their chronic conditions at home, provides updates to the medical team when necessary, and ultimately aims to reduce hospitalizations,” said Kristina Niehoff, PharmD, who oversees the CDM program.

“Many of our home health patients live alone and do not have family or friends who can help,” she added. “So, we are either coaching the patient or their advocate on what to do and what to ask at medical appointments, or we are being the advocate for those who don’t have that extra voice.”

In Robinson’s case, she was being seen by a Vanderbilt Home Care physical therapist at her home, as ordered by her primary care provider to address increased pain. The therapist noticed the medications in Robinson’s medical record didn’t quite match what she was taking at home and contacted Niehoff for a review of her medications. Robinson was also experiencing chronic gastrointestinal distress which Niehoff identified as potentially linked to her medication. These concerns, combined with her Type 2 diabetes and heart failure, made Robinson a candidate for the CDM program.

While the foundation of the CDM program is the regular telehealth calls from Probst, Niehoff can become more involved with a patient’s case if medication issues arise. She was able to work with Robinson’s primary care provider to reduce the dosage of one medication to minimize side effects while maintaining its effectiveness.

“In Mrs. Robinson’s case, the CDM program had provided twice weekly check-in phone calls to assess symptoms and vital signs and gave additional opportunity to provide the necessary education for her chronic conditions,” Niehoff said. “Every time I called, she had already taken her weight, blood pressure and blood glucose and was ready to discuss the values, which were all within the proper range. When she called to say, ‘My blood pressure is 200, and I’m having a headache,’ I was surprised.

“Because of the close contact we have with our patients, we understand their baseline demeanor and can easily detect when something is out of the normal range. Knowing the key players in her care, we can quickly communicate new symptoms or changes.”

The CDM program began in February 2022 but really took off last summer as COVID-19 cases began to decrease significantly. It is modeled on the Medical Center’s successful COVID-to-Home program, a joint program staffed by Vanderbilt Health OnCall and Vanderbilt Home Care Services to better care for high-risk individuals who tested positive for COVID-19 at Vanderbilt Health sites. These patients received regular phone calls to assess their symptoms and vital signs, in addition to in-home nursing visits.

“Patients come to Vanderbilt Home Care at a time of increased vulnerability,” said Tara Horr, MD, chief medical adviser for Vanderbilt Home Care Services. “There is no one-size-fits-all model that is right for everyone. Some patients have higher symptom burden, more complex medication regimens, and are at tremendous risk of disease exacerbation. The increased ability to stay in communication with the patient over this time, by having nurse calls at regular intervals, allows for improved patient empowerment and ability to self-manage their chronic disease, as well as earlier detection of changes in health status that can bring earlier intervention.”

During its first full year of operation, 296 patients received care from the CDM program team, and they were followed an average of 32 days. Between 30 and 35 patients at a time are identified for CDM from Vanderbilt Home Care Services’ average daily census of 600 to 800 individuals.

Recent hospital readmission rates for patients served by the CDM program have been lower than the rate for the Medical Center’s entire home care population. In January 2023, the readmission rate was 6%, and in February it was 8%, said Niehoff. While the telehealth service is not currently a reimbursable expense, beginning in July home health agencies have been asked to report these types of telehealth calls made to Medicare enrollees to the Centers for Medicare & Medicaid Services.

“Our hope is that someday we can provide these telehealth services across our entire home health agency,” she said. “We saw clear benefits with the telehealth services provided from our COVID-to-Home program and have continued to experience similar success with the CDM program. In the future, we also hope we can be reimbursed for these telehealth services. Many home health patients can benefit from check-in calls from a nurse to address their health goals, management of their chronic conditions, and to ensure they have the appropriate medicines, supplies and education to successfully manage their health at home.”

As for Robinson, her praises of the CDM program are unreserved.

“The outreach, as far as them checking on me, has been tremendous,” said Robinson. “I really appreciate it because they have given me comforting words that help with whatever I’m going through. I can stay calm and happy, in spite of the way I feel sometimes. I love the service, and I love the people I’m assigned to. I love the calls two days a week, but I wouldn’t mind if they called me every day. That’s just how good I feel.”