Corresponding Author(s)
Norman E. Vinn, DO, MBA, 260 Calle Campesino, San Clemente, CA 92672.
E-mail address: nvinn@housecalldrs.net.
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The population of the United States is aging. Current health care costs are nearing 17% of the gross national product (GNP).1 These costs are projected to increase sig- nificantly over the next decade. A significant component of overall health care costs is attributable to the Medicare population. Current Medicare enrollment is >44 million and is projected to increase to 55 million by 2016.1,2 Medi- care spending alone accounts for 3.2% of the gross domestic product.1,2 According to a recent article in The Los Angeles Times, only 10% of the Medicare population—most of whom have multiple chronic conditions—account for two- thirds of Medicare spending.3 In addition, one quarter of Medicare spending, on average, occurs in the last year of life.4
In addition, there is significant discontinuity of care within the Medicare population. Although high-profile de- bate continues about access to care for the uninsured, there is a “hidden underserved” population within our midst that suffers from a lack of primary access to clinicians. This population is both costly and well-insured. This hidden underserved population is the high-risk, homebound, frail, elderly patient. In addition to suffering from multiple, com- plex comorbidities, many frail elderly individuals have physical mobility issues that limit ambulatory access to physicians. In addition, many of those frail elderly have other functional compromises. According to testimony be- fore the Joint Economic Committee, as many as 6% of older adults living in the community (2 million people) are se- verely disabled.5 These individuals report challenges with three or more activities of daily living (ADLs). This group of older adults is far from independent, and require in- creased caregiver services.5 Many have limitations in their ability to perform self-care, and they lack control of bowel and bladder functions. Many have safety and/or nutritional issues. Others have difficulty with cognition that may affect compliance with daily medications. Many have psychoso-cial issues including isolation, depression, and financial issues, which hinder availability to caregiver resources.Among this underserved population, physical frailty, combined with a lack of access to and continuity of care, leads to a progressive decline in health status, culminating in an acute clinical crisis. Once in crisis, 911 is called and the patient is transported to a local hospital’s emergency department (ED). Per data cited in the Institute of Medicine(IOM) reportRetooling for an Aging America, once treated in the ED, older adults are more likely to have an overnight hospital stay and are also more likely to have multiple overnight hospitalizations.6,7As many as 27% of those admitted will be transferred to a skilled nursing facility(SNF). 5
To further complicate matters, many patients and their families have a poor understanding of the natural history of disease, of likely prognosis, and of the pros and cons in options for aggressive vs. palliative care. Many patients have no concept of homeostasis or “balanced” health, whereby the body is able to achieve a sustainable health status through combined internal and interventional re- sources. Many do not understand that a gastric enteral nu- trition tube (g-tube) is a method of administering nutrition without the valued component of oral gratification. They do not understand the pattern of downhill sequelae, when treat- ment of one problem leads to a daisy chain of new problems and homeostasis cannot be restored. Because of a lack of education and awareness, many patients and their families have unrealistic expectations about care options and con- tinue to pursue a well-intentioned but ineffective course of aggressive, futile care.
Many of these patients move through a revolving door of acute care. They have multiple hospital admissions and re-admissions. One-fifth of patients hospitalized are rehos- pitalized within 30 days of discharge.8 The combination of these aforementioned factors results in an excessive rate of ED visits, primary hospitalizations, and rehospitalization within 30 days of discharge.8 Furthermore, close to 50% of patients readmitted to the hospital within 30 days of dis- charge have not had an interim visit with a physician.6 That rate, combined with the lack of postdischarge visits, would suggest that many of those readmissions are avoidable. In summary, reactive emergency interventions are often “too little too late,” are often not cost-effective, and are of lim- ited value in achieving sustainable improvements in health status.
Existing resources and persistent gaps in continuity
The hospitalist model is a medical care system that focuses on expertise and efficiency of care within a hospital setting.
This model has proven over time to be widely accepted for its value in maintaining focus of outpatient physicians on ambulatory medicine while sustaining efficiency of inpa- tient care and cost-effective use of hospital resources.9 However, efficiency of inpatient care creates pressure to expedite the course of care and to discharge patients whose health status remains quite fragile. This expedited course of care affects care transitions and postdischarge continuity.
When postdischarge continuity is compromised, the rate of hospital readmission remains excessive. The IOM cites Parry et al.: “Older adults are especially vulnerable as they transition between types of care. A lack of coordination among providers in different settings can lead to fragmen- tation of care, placing older adults at risk for absence or duplication of needed services, conflicting treatments and increased stress.”9 Furthermore, in the IOM’s Crossing the Quality Chasm, the authors conclude: “This type of frag- mented care . . . (is) exemplifying the failure of the health care system to meet the standards of quality (most notably safety, efficiency, and patient-centeredness).”8
There are several correctable reasons for postdischarge gaps in care. One is an incomplete understanding on the part of inpatient and ED discharge planners about the potential gaps in care that occur with frail or cognitively impaired postdischarge patients. Discharge planners typically are charged with creating and delivering (in collaboration with the inpatient or ED physician) an appropriate, written, post- discharge plan of care. The objectives of this plan are multifold. First, the plan provides written documentation that a discharge plan was drawn up and given to the patient. Second, the plan should educate the patient and family about the discharge plan and enhance continuity. Third, the plan should help to identify and pre-empt potential gaps in continuity and compliance.
Discharge planning instruments and forms often consist of a preprinted instruction form, a list of medications to be taken postdischarge, and additional instructions that include recommendations for the patient to see an outpatient phy- sician within a specified number of days after discharge. Often, there is no specific differentiation between “routine” discharge planning vs. special planning for the patient who is at high risk for re-admission (a HRRA patient). Finally, there may be a limited understanding or use of evolving resources to improve postdischarge compliance and conti- nuity.
One of those emerging resources is the growing cadre of home care clinicians (physicians and midlevel practitioners) who specialize in going to the patient rather than waiting for the patient to come to them. In fairness to both inpatient and ED discharge planners, there are real and implied barriers that potentially limit their ability to embrace and access this resource. Those barriers include managed care authorization protocols, hospital “privileging” questions concerning refer- rals to outpatient physicians who may not be on staff, and historical customs regarding continuity of care protocols between inpatient and outpatient services. In the latter case, there is an implied obligation to refer the patient back to the and primary care physicians is even lower, occurring only 3 to 17% of the time.12
One of the great opportunities emerging with electronic health records is the ability to expedite transfer of critical information. Information should be mobile between sites of care. Although all stakeholders would agree in principle with this axiom, movement of information between sites of care is typically slow or nonexistent. Outpatient primary care physicians infrequently get full or timely records on patients who have been to the ED. Pertinent inpatient records such as the history and physical examination, lab- oratory studies, and discharge summary may not be deliv- ered to the outpatient primary care physician in a timely fashion. Because of HIPAA restrictions, records may not be sent to the postdischarge health care provider with the greatest “need to know.”
Finally, there is often a limited patient/family under- standing of the natural history of disease. This lack of understanding may lead to unrealistic expectations. With the fast pace and course of hospital care, there may be little time to assemble the patient and key family members and discuss prognosis, treatment options, and the pros and cons of choosing an aggressive vs. palliative course of care.
After hospital discharge, patients and/or families may call the primary care physician with concerns and questions. If we are to believe the statistics, 50% of the time the physician has not seen the patient since discharge.8 Even more often, the ambulatory physician has no key discharge information. In addition, if the patient calls after working hours, the physician responding to the call may be a member of an extended “call panel” with no knowledge of the patient and limited or no access to the patient’s record. In all of these circumstances, a defensive medicine posture in understandable. The safest course of action becomes referral back to the ED, where there is a high likelihood of read- mission.
Discussion
Over the past 12 years, the hospitalist model of care has become common practice in most hospitals. What was once an innovative challenge to traditional models of care has now become a standard of care in the community. However, the time has come for next innovation in the care conti- nuum. The hospitalists do their jobs well and need to focus on their core competency within the walls of the hospital. Discharge planners are dedicated individuals who work hard to follow traditional procedures and be sensitive to medical politics. However, it is clear that post-discharge care has significant gaps and could be improved. The es- sential—and now well-defined—role of the hospitalist in inpatient care suggests that parallel skills and practices are needed to effectively manage the postdischarge patient who is homebound and/or at high risk for readmission.
The Key Question: How do we improve continuity and access among frail, homebound, and HRRA patients; improve symptom management; improve compliance andquality of life; improve patient family expectations; de-crease unnecessary morbidity; and reduce unnecessary useof limited health care resources?
The Answer: Effective integration of the home careclinician into the continuum of care. We propose a newnomenclature to describe this clinician. We propose that thisclinician be referred to as a residentialist.
Evolution of the home care model: defining residentialist care
First, it is crucial to understand—and accept—that there arenot three, butfour, essential stops on the continuum of care:office, hospital, skilled nursing facility, and home. Theresidentialistis the home-based counterpart to the hospital-ist. Thehospitalistexercises special expertise within thewalls of the hospital. Theresidentialistprovides specialcompetency within the walls of the patient’s home. Al-though home health nursing is a crucial component ofhome-based care, the home health nurse is not—and wasnever meant to be—a surrogate for physician services incomplex patients with multiple comorbidities and a highrisk for readmission.
It helps to acknowledge that sometimes, something veryold becomes something very new. The oldest form of med-ical care delivery is the house call. However, as health carehas evolved to its current state, access to clinical careservices has been fulfilled primarily in three sites of care:the office, the hospital, and the skilled nursing environment.For historical perspective on this evolution, one mustnote that until the late 18th century, office practice did notexist. However, with increasing medical specialization, ad-vancing diagnostic and treatment resources, defensive med-icine, and methodologies of third-party reimbursement, thehouse call, once the outpatient care standard, drifted to nearextinction by the late 1980s. House calls were viewed as aquaint curiosity by the medical community, and as a virtualnonoption by patients and families. In the late 1990s, owingto the dedicated efforts of a small, passionate group ofphysicians, Medicare began to recognize both the value andthe unique work effort for care rendered in the home envi-ronment. In 1998, Medicare established a set of uniquereimbursement codes for physician home care. Further evo-lution occurred in the new millennium with near-equivalentreimbursement of “domiciliary” codes for care rendered inan assisted living facility or licensed residential board andcare home. As aresult, a new generation of mission-drivenhouse call physicians and midlevel practitioners has emergedin various urban and rural regions of the United States. Al-though the practice styles and models of care have variedwidely, thetarget patient population (the homebound, frailelderly), as well as the widespread passion for home carepractice, has been remarkably homogenous.With regard to current care models in the home, thespectrum is wide, ranging from solo practitioners, to both small and large groups, to academically-oriented,university-based programs. Some models have emphasized collabora-tion with clinicians and clinical service providers at othersites in the care continuum. However, despite the commontransition of homebound patients back and forth to othersites of care, much of care in the home has remainedfragmented. This built-in discontinuity has typically notbeen the preference of the home care clinicians, but ratherhas persisted because home care is a disruptive innova-tion.12In disruptive innovation theory, new innovations andchanges typically come from the margins, and are oftenresisted by mainstream stakeholders who view change asthreatening to the status quo.
Although most home care clinicians have been open to collaboration with other clinicians, the practice of home care medicine has remained, for the most part, a poorly understood and marginally accepted practice model. Office clinicians, hospitalists, skilled nursing clinicians, hospital discharge planners, and non-Medicare third-party payers have been slow to recognize—and value— effective conti- nuity at all four stops on the continuum of care. For a multitude of reasons, they have not fully grasped that home care clinicians are a value-driven resource for the hands-on care of high-risk, homebound patients who cannot or will not access other sites of care after discharge from the hos- pital or skilled nursing facility. Although care issues among ambulatory patients have typically been addressed by a mandatory office visit, the needs of frail, high-risk, home- bound patients ironically have been entrusted to home health nurses without the benefit of hands-on physician care. Too often, the outcome is a frantic transfer to the ED when the patient has declined to a crisis point. As previously referenced, this pattern has occurred repeatedly with multi- ple hospital readmissions and, often, futile care.
In fairness to other stakeholders, low use of home care clinicians rests more with ignorance of the availability and role of home care clinician resources rather than outright bias. “Out of sight, out of mind” might be a fitting descrip- tion. The home-based clinician is often left out of the equa- tion at the point of discharge planning from an inpatient environment. Both hospital physicians and discharge plan- ners are not accustomed to the luxury of having new access and continuity options for the homebound patients and pa- tients at high risk for readmission. Out of clinical habit, these individuals opt for what they do understand: home health nursing care plus hopes and expectations for a timely follow-up visit to an ambulatory care clinician. In fact, the latter option has proven to be problematic. As previously cited, 50% of patients had no evidence of a physician visit between the original admission and the subsequent hospital readmission. Other studies cited in the IOM report support the premise that discharge planning is often less than fully effective.8,10,12,14
Both the problem and the opportunity are likely to be magnified. Under proposed health care legislation, the pen- alty to hospitals for patients readmitted within 30 days is likely to increase substantially. Despite aggressive dis-
These discussions highlight both challenges and oppor- tunities to improve use among the most costly Medicare population, and reduce costs at the most expensive site of care—the hospital. Clearly, a crucial player in this initiative is the clinician who provides care in the home.
The residentialist model of care
Residentialists are clinicians who are specialists in onsite care of the homebound, frail, elderly, and high-risk patient. Residentialists are comfortable with multiple complex co- morbidities. These clinicians focus on the whole patient and understand that the psychosocial, nutritional, safety, and/or cognitive issues may have a greater impact on the patient’s course of care than the dosage of medications for such underlying conditions as congestive heart failure or diabe- tes. Residentialists view themselves as advanced case man- agers who aggregate resources and oversee a comprehen- sive plan of care for the patient. Residentialists advocate for coordinated home care resources— clinical, nutritional, psy- chosocial, and environmental—to maximize quality of life and health status in the home environment. They are high- tech, high-touch clinicians who welcome the opportunity to have a compassionate, sensitive, but candid discussion with patients and families about the natural history of disease prognosis, alternative treatment options, and patient prefer- ences for Advance Directives. Residentialists are accessible both in person and by phone to discuss new symptoms and recommendations. By nature, they are not oriented toward defensive medicine but are willing to carefully listen to a patient’s symptoms and preferences before recommending ED transport and aggressive care.
Disruptive innovations will continue in health care. Resi- dentialist care is a disruptive innovation and currently sits where the hospitalist model sat in 1996. Among the growing population of home care physicians in the United States, most are highly mission-driven and dedicated to care of the frail elderly and the hidden underserved. Although united by the common bonds of passion for this model of care, they are still in evolution as a defined and well-understood player in the health care continuum. A number of innovative pro- grams have explored the potential of clinician and team- based care in the home, including the GRACE Program, the PACE program, the Virginia Commonwealth University Medical Center program in Richmond, VA,3,17,18 as well as
a number of innovative homebound programs in Southern California. All of these programs have delivered encourag- ing results and include home care clinicians practicing, in effect, what we describe as residentialist care. As the resi- dentialist competency progresses to mainstream acceptance as the preferred resource for continuity and care in the home, other multisite collaborative care models will con- tinue to evolve. The next frontier will be development of improved and standardized models of care that enhance seamless care transitions among hospitalists, residentialists, SNF clinicians, and ambulatory care clinicians.
Conclusions and recommendations
For high-risk, homebound, frail, elderly patients, we must ensure access and continuity at all four points on the con- tinuum of care—ambulatory clinic, hospital, skilled nursing facility, home. We also must continue evolution of the residentialist model as a new, powerful care mechanism. This new and unique model of practice should include required training, expected skills, and a case management approach that defines clinical objectives of care, assessment and management methodologies, and standards of docu- mentation, communication, and movement of information during care transitions. For optimal care of populations, the model should be consistent and should be available over a broad geographic service area.
We must continue to encourage the development and integration of collaborative models of care that span all sites on the continuum of care. Furthermore, we must improve awareness among all stakeholders—physicians, discharge planners, payers, patient, families—about evolving models of cost-effective care for homebound, frail elderly and HRRA patients.
Discharge planning must also evolve. Discharge plan- ning should be a collaborative, realistic, customized pro- cess, not merely a “one size fits all” set of proscribed procedures and standard forms. Although many discharge procedures and instruments are accreditation-driven, it is ironic that in a world focused on continuous process im- provement, accreditation compliance may hinder an inno- vative evolution of customized discharge planning proce- dures. Those procedures should identify HRRA patients and be tailored to reduce the risk of hospital readmissions. Discharge planners must understand that Home Health Nursing, Durable Medical Equipment, a medication list, and instructions to see the primary care physicians do not con- stitute a plan of care for homebound and HRRA patients. In collaboration with inpatient physicians, they must identify patients at high risk for readmission; crystallize outpatient follow-up; aggregate necessary resources; and address is- sues of safety, nutrition, medication compliance, and psy- chosocial support. Where appropriate, they should work with families to ensure access to in-home care providers.
Discharge mandates should include confirmation of cru- cial conversations between inpatient and outpatient physi-
We hope that this treatise will increase awareness of the emerging role of the residentialist in the American health care system. We also hope that it will spark both discussion and debate, as well as further innovation, adoption, and research as the model of care continues to evolve.
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