JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP213 – Managing Hospital Readmissions: Transitional Care Management Medical House Calls

Jun 12 2019
12:30 pm - 2:30 pm

PP213 – Managing Hospital Readmissions: Transitional Care Management Medical House Calls

Vulnerable, homebound older adults are highly susceptible to unplanned 30-day hospital readmissions, which is costly for the health care system. As a result, health care expenditures for this population continue to rise. Studies have shown that transition of care programs, when complemented with home-based primary care delivery may improve health care outcomes for this population. Medical house calls as a component of transitional care management (TCM) in the management of 30-day hospital readmissions showed better patient outcomes in terms of polypharmacy reduction and correlated predictors of readmission. As a secondary outcome, point-of-care concerns were addressed. Medicare beneficiaries 65 years or older who were discharged from skilled nursing facilities to home were offered a home visit by a nurse practitioner (NP). Results showed that this emerging trend in patient-centered approach opens opportunities for case management approaches. The use of LACE Index scores guided the prioritization of 145 visits.  Most patients experienced two comorbidities, with hypertension being the most common, and heart failure was a significant predictor of unplanned 30-day hospital readmissions. Medications were reduced after medication reconciliation from 17 to 11, which was statistically significant (z = -7.497, p < .001). Almost half of the patients required prescriptions during the visit, and more than half were unable to see their PCP for 14 days or more. This demonstration has shown that older adults discharged from a higher level of care can benefit from TCM through medical house calls by a NP within 14 days after discharge. Visits significantly reduced polypharmacy, provided a way to get prescriptions that would otherwise be unobtainable from a PCP for 14 days or more after discharge, and, therefore, managed readmission risks. 


1. Participants will get perspective from a demonstration of medical house call by a Nurse Practitioner in Transitional Care Management

2. Participants will synthesize approaches to incorporating an emerging modality to addressing 30-day unplanned ER/hospital readmissions

3. Participants will apply learning from the discussion into specific work areas of case management, whether from a hospital or skilled nursing facility discharges