Geriatrics COVE Team Makes House Calls and Reduces Readmissions

With nearly 11% of Dallas County residents aged 65 or older, a large population in our community is struggling to get the primary and preventive care they need.

Approximately 25% percent of patients 65 and older on Medicare have difficulty performing at least one activity of daily living (ADL), such as self-care. By age 85, 40% to 53% of patients were unable to perform at least one ADL.

As such, hospital readmission has become a major stressor for patients and health systems. Under the Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program, six conditions/treatments are under scrutiny:

• Acute myocardial infarction
• Chronic obstructive pulmonary disease
• Heart failure (HF)
• Pneumonia
• Coronary artery bypass graft surgery
• Elective primary total hip or total knee arthroplasty

The Connection? Patients with these conditions often are elderly and dealing with temporary or ongoing mobility challenges. Pair that with frequent primary care visits required for chronic conditions such as high blood pressure or diabetes, and patients and providers are set up for low adherence and increased need for advanced or emergency care.

In response to these cumulative concerns, UT Southwestern launched Care of the Vulnerable Elderly (COVE) in 2015 – a home-based primary care (HBPC) program backed by an interdisciplinary team.

HBPC programs like COVE saved Medicare approximately $10 million in 2016 in costs for care for chronically ill patients. This savings was due in part to fewer 30-day readmissions and reduced Emergency Department utilization and hospital admission for chronic conditions.

In Just Four Years, COVE Has Grown From 70 Patients to 350. Two major components of COVE’s success are the patient-centric approach to preventive care and the behind-the-scenes collaboration between our geriatric experts and their multidisciplinary colleagues.

Interdisciplinary Team Collaboration 

The Approach

Successful HBPC programs are led by advance practice providers (APPs) and physicians experienced in managing the primary care of patients with multiple chronic conditions, per data from Independence at Home, a demonstration program by the Centers for Medicare & Medicaid Services (CMS).

COVE is staffed by advanced practice NPs and doctors who are specially trained in geriatrics, as well as a clinical social worker, a clinical coordinator, and a registered nurse with geriatric expertise.

In the home, the team can provide nearly any type of care performed by a clinic. This includes physical exams, vaccinations, phlebotomy, EKGs, cortisone joint injections, and mental health screenings. Advances in mobile equipment such as ultrasound have made it possible to do both evaluation and management in the home setting. Thus, the in-home team can divide and conquer based on patients’ needs and goals of care.

The Connection

Recognized by U.S. News & World Report as one of the top 20 hospitals in the country for geriatric care, UT Southwestern is uniquely positioned to take this concept a step further by liaising between patients and our specialists on campus.  

While some patients will have to come in for advanced exams and procedures, the team can securely communicate data and preferences between those patients and their specialists to reduce the need for multiple trips to campus.

Home Health Agency Partnerships

Additionally, COVE partners with home health agencies to help maintain patients’ health at home. Under this model, COVE has shown significant reductions in 30-day rehospitalizations, which reflects national trends.

For example, communication and care-planning tools under the INTERACT model (Interventions to Reduce Acute Care Transfers) have been shown to decrease hospitalizations by approximately 25 a year in a 100-bed facility.

A 2016 study in Circulation: Cardiovascular Quality and Outcomes found that nurses collaborating with pharmacists during a patient’s transition from hospital to home can reduce HF medication-related 30-day readmissions. Additionally, physical therapy care at home was shown to reduce readmission by 16% in patients with HF.

Related reading: UT Southwestern POSH Program (Perioperative Optimization of Senior Health)

Patients and a Caregiver-Centric Approach

Patients and their primary caregivers tell us they feel supported by the COVE program – as if they’re partners with their in-home providers. 

All patients receive personal attention, along with the aforementioned team approach to care. In this model, we can provide a more personalized experience. While we still have a full day of patients to see, there is no waiting room queue and less risk of delays due to other patients’ emergencies.

COVE also increases opportunities for precision medicine. We get more one-on-one time to discuss proactive health care, such as:

• Diet, nutrition, and exercise
• Medication adherence
• Preventive screenings
• Self-exams, such as checking for diabetic ulcers
• Vaccinations, including the influenza and pneumonia

Additionally, the home-based program can screen for and alleviate some caregiver burdens, such as stress related to scheduling planned and acute visits.