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Impact of a Social Home Visit on High-Utilizing Patients in a Residency Continuity Clinic January 31, 2015

Stephanie Nothelle, MD; Colleen Christmas, MD FACP; Laura Hanyok, MD

Johns Hopkins Bayview Medical Center

Disclosures

• I love home visits

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Roadmap

• Background• Methods and Objectives• Results• Conclusions

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Background: The struggle

• The majority of health care resources are used by a small group of people often called “high utilizers”1

• “High utilizers” often have complex social needs in addition to complex medical needs2,3 and are more likely to be perceived as “frustrating” by their provider4

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Background: The BayviewPatient Connection

• Multi-faceted intervention based on knowledge of high social needs and that knowing your patient well can help physicians feel more competent about the care they provide5

• Home visits may be a way to help physicians better understand their patients’ lives6 and could be particularly useful in working with “high utilizers”

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Methods: Patient Selection

• 2011-2012: Medicaid patients with 4 or more inpatient admissions or ED visits and attended at least 3 clinic visits in the prior year

• 2013-2014: A separate program, Johns Hopkins Community Health Partnership (J-CHiP) identified Medicare and Medicaid patients using a risk model

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Methods: Home Visits

• Each patient is contacted and offered a home visit, matched with a PGY-1 (n=45)

• Goal to learn about the patient’s barriers and facilitators to care and health beliefs and given worksheet to help guide visit

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Methods: Home Visits

• PGY1 records what they learned about the psychosocial aspects of the patient’s care in the medical record

• PGY1 debriefs their experience with the group, reflecting on how the experience could contribute to patient care.

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Methods: Home Visits

• Supervised introductory home visits for high utilizing patients started in the summer of 2011 and was repeated in 2012 and 2013

• All residents were surveyed in 2014

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The home visit…

Helped me provide better care for my patient

Helped me get to know my patient as a person

Was important in building a relationship with my patient

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Based on this experience I am more likely to do another home visit

The home visit was a personally rewarding experience

• I found that she was doubling up on her statin taking the "generic" and "brand name" daily, which she believed to be different medications.

 • I felt like I really had a connection with my

patient after the home visit. I was able to be more sympathetic to her pain after understanding how demanding it is to have 5 kids to care for at home.

• I have done home visits for other outpatients due to this training.

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Conclusions

• A home visit focused on a patients psychosocial characteristics prior to the first medical visit can be a powerful tool for interns to understand a high utilizing patient better as a person

• Visiting a patient at home prior to seeing them in the office improves the physician’s perception of care they are able to provide, which has previously been associated with decreased burnout

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Conclusions

• Completing a home visit on a high utilizing patient may influence a house officer’s care of other patients and is a rewarding experience.

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References

1. NHE Fact Sheet National Health Expenditure Data. https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_sheet.asp. Accessed 8/30/2011, 2011.

2. Super Utilizer Summit “Common Themes and Innovative Complex Care Management Programs” October 2013 http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407990

3. R.G. Kronick, M. Bella, and T.P. Gilmer. The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions. Center for Health Care Strategies, Inc., October 2007.

4. Lin et al “Frustrating Patients” Journal of General Internal Medicine. May, June 1991. Volume 6, Issue 3, pp 241-246.

5. Schultz et al, “Emotional effects of continuity of care on family physicians and the therapeutic relationship.” Canadian Family Physician. February 2012 Vol 58 No 2 pp 78-85

6. Young et al “The Home Visit in the Multidisciplinary Teaching of Primary Care Physicians” Academic Medicine April 1981 Volume 56 Issue 4

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