On the Go: How Home Care Services is Innovating Care Delivery
A Partners nurse practitioner (NP) knocks at a patient’s front door with a medical bag tucked under her arm. Although this may sound like a scene from the past, at-home care services are once again at the forefront of care delivery. At Partners, we have several at-home care models and continue to expand. One program, the Partners Mobile Observation Unit (often referred to as the PMOU), is redefining the way we handle care for conditions like heart failure and upper respiratory infections for seniors who may find it difficult to get to their doctor’s office. What started as a pilot at Massachusetts General Hospital (MGH) in the spring of 2013 with only 16 admitted patients has now spread across the Partners network, providing coverage to the greater Boston area as well as the North and South Shore, with 623 patients admitted to PMOU in the past year.
The PMOU program, which is supported by Partners HealthCare at Home and Center for Population Health, was conceived as a way to manage chronically ill patients outside of the highest levels of acute care, namely the emergency department (ED). The idea was that by caring for straightforward, chronic conditions outside of the ED, they could cut long wait times, reduce the cost of in-hospital treatments, and provide higher quality care to patients.
“It was kind of a slow start,” says Dana Sheer, NP, Director of the PMOU program. Over time, the program gained traction as an ED avoidance strategy with primary care physicians (PCPs) referring patients to the program. “At MGH, it took a lot of ‘door to door’ conversations, practice by practice, getting the word out,” says Ryan Thompson, MD, physician lead for PMOU implementation at MGH. “It took a dedicated team who led a hands-on approach to increase referrals among PCPs.”
Typically, if a patient calls their PCP’s office with a change in medical status (such as trouble breathing or pain when urinating), the PCP or triage nurse will recommend urgent evaluation, often in an emergency department. But with the PMOU, physicians can deploy a nurse practitioner into the patient’s home to do an evaluation, diagnostics, and put together a treatment plan. “We’ve been able to serve chronically ill, frail, challenging patients and keep them out of the hospital,” says Sheer. In addition to PCPs, the program has gained traction among triage nurses and care managers for medically complex high-risk patients in our Integrated Care Management Program (iCMP). “They’re often the ones getting the call on the front lines, and don’t always have options for urgent care aside from the ED,” says Thompson.
Pia Young, RN, an iCMP Nurse Care Manager at Brigham and Women’s Hospital, explains that if a patient, family member, or caretaker calls her with a clinical concern, Young’s first thought is to call PMOU. “Their response is almost immediate,” Young says. She appreciates the NP’s for their thorough visits, ongoing consultations with the primary care team, and dedication to maintaining care continuity. “The PCPs and iCMP nurse care coordinators have grown to rely on them greatly.”
The PMOU is designed for high-risk seniors who find it difficult to travel for appointments. The average age of PMOU patients are in their mid-eighties, and the oldest is 107 and living independently at home. “Imagine what it must be like, in the dead of February, with or without snow, for a woman who is 107 years old to get in urgently to see her PCP when she’s not feeling well,” says Sheer.
Given the success of the PMOU program, Partners’ emergency department physicians have joined PCPs and Care Managers in referring patients to the program. In fact, Brigham and Women’s Hospital and Massachusetts General Hospital recently launched an even more intensive at-home pilot program called Hospital-at-Home. In this pilot, patients with specific conditions (pneumonia, heart failure, chronic obstructive pulmonary disease, and certain infections) receive some medical care and monitoring which has traditionally been delivered only in hospitals.
PMOU and its expanding pilot programs have a tremendous impact on patient satisfaction and cost of care for certain high risk seniors. Not only is it making patients’ lives easier by eliminating complicated transportation arrangements, long wait times in the ED, and increased risks associated with hospitalization such as hospital-acquired infections, confusion, and disability —it has reduced costs for hospital-related expenses. For example, 200 patients referred to PMOU from MGH saved approximately $0.5 million.
“PMOU has been a real benefit for the MGH Senior Health Practice. They have taken care-accessibility for our frailest geriatric patients to the next level, by acting as our eyes and ears in the home setting,” says Ardeshir Hashmi, MD, Medical Director of MGH Senior Health. “The care management home-based plans are comprehensive and very effective in closing the loop with our Geriatrics PCPs.”
This approach will not work for every patient, and decisions about participation always put patient safety first. “But for a patient who might just need antibiotics, and a quick check in with a nurse once or twice a day, getting care at home just makes more sense,” says Thompson. “The home care models for complex high risk patients allow patients to receive care in the comfort of their own homes. In addition, as a health care system, these models of care are pushing us towards more cost-effective and appropriate care.”
Learn more about PMOU in our recent PBS News Hour segment.