Hospital-Home Transition Care Program (H-HTCP)

A Joint Program of NOVA House Call MD & American Care Partners @Home

Re-hospitalization is prevalent, extremely common among the chronically ill and elderly populations, and expensive to our health care system. The U.S. has an 18 percent rate of hospital re-admissions within 30 days of discharge and an alarming 76 percent of these are preventable, according to the Center for Technology and Aging.

Finding and receiving adequate follow-up care after a hospitalization is a challenge thousands of aging adults face every day. Patients encounter many obstacles while transitioning from a hospital or brief skilled care nursing home stay to becoming independent again in their homes. Often, these transitions are characterized by inadequate communication, omission of critical medications, inadequate discharge planning, and serious gaps in care during transfers to and from hospitals all leading to preventable declines in health status. These poor “hand-offs” are extremely common, especially for the chronically ill high-risk and frail older adult population. As a result, re-hospitalization is frequent and seemingly inevitable for these patients.

Our Hospital Transitional Care Program (H-H-TCP) provides comprehensive in-hospital or In-Skilled care facility planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

    H-H-TCP is developed to:
  • Prevent avoidable hospital re-admission and emergency room visits for primary and co-existing conditions by addressing the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute or sub-acute care setting to the home.
  • Enhance patient and family caregiver satisfaction by Preparing and assisting patients and family to more effectively manage changes in health associated with multiple chronic illnesses.
  • Improve in health outcomes after discharge. Holistic Improvements in physical health, functional status, and quality of life.
  • This is accomplished through early identification of patients’ goals, development and implementation of individualized plans of care, application of effective communication, and the adoption of evidence-based care.

      The Hospital to Home Transition program is currently available for patients who meet the following criteria:

    • Chronically ill high-risk older adults with multiple chronic medical conditions
    • Multiple Medications/Complex therapeutic care
    • Medicare or Medicaid eligible
    • Resident of Northern Virginia
    • Discharged to home from a hospital or brief Skilled care Nursing home/Rehab facility

    For clients who suffer from multiple chronic conditions and complex therapeutic regimens, H-H-TCP emphasizes coordination and continuity of care, prevention and avoidance of complications, close clinical treatment and management and re-hospitalizations – all accomplished through well organized and planned transition care program with a physician oversight.

    H-H-TCP is a multidisciplinary model that includes House Call physicians, nurses, social workers, discharge planners, Clinical pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients’ and caregivers’ ability to manage their care.

    Our H-H-TCP includes the following essential elements:

      The team consists of House call Board certified Physician, RN, LPNs, Social worker and CNAs.

    • In-hospital or In-skilled care nursing home assessment, preparation, and development of an evidenced-based plan of care;
    • Physician-nurse-social worker designed comprehensive care plan
    • Regular home visits by the TCP team members with available, ongoing documented telephone support (seven days per week) through an average of two months post-discharge;
    • Comprehensive, holistic focus on each patient’s needs including the reason for the primary hospitalization as well as other complicating or coexisting events;
    • Active engagement of patients and their family and caregivers including education and support;
    • Emphasis on early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to re-admissions;
    • Multidisciplinary approach that includes the patient, family, informal and formal caregivers are part of a team;
    • Communication to, between, and among the patient, family, caregivers, and health care providers and professionals.

    How Does H-H-TCP work ?

    The Hospital Transitional Care Program targets older adults with two or more risk factors, including history of recent hospitalizations, multiple chronic conditions or on multiple medications.

    Home visits are an essential component of the Program. The H-H-TCP case manager must see in order to understand how patients and family/caregivers are managing symptoms, and to determine if the living situation could prove problematic to the patient’s health (e.g., the presence of mold in the apartment of a COPD patient; plants that could cause allergies; stressful living conditions), Safety of the patient in completing activities of daily living (ADLs, including bathing, walking, toileting, etc.) and instrumental activities of daily living (IADLs, including shopping, housework, etc.) is assessed, recommendations for adapting the environment are made, and referral to area senior agencies are completed, if needed.

      The following typical visit schedule is utilized under the program – Patients are visited:

    • In the hospital within 24 hours of request/referral;
    • Scheduled Visits throughout the hospital or Rehab facility stay;
    • In the home within same day of discharge from the hospital or Skilled care facility
    • At least weekly during the first month;
    • At least semi-monthly through the duration of the intervention;
    • Seen by the assigned House call Physician Within 24 hrs of discharged;
      • Additionally, Case manger RN:

      • Maintain daily telephone availability in order to respond to patients’ and caregivers’ needs and concerns;
      • Provide patients and caregivers with a written plan with instructions and phone numbers of the assigned house call physician, and ambulance services for emergency care; and
      • Initiate telephone contact with a patient during any week that a patient is not visited at home.

    In-Hospital Visits with Patients

    In the acute or Sub-acute inpatient setting within 24 hours of requests for service is made, the assigned H-H-TCP Case manager (Clinical social worker or RN) conducts a comprehensive assessment of the patient’s health status and defines priority needs and services for the patient and family throughout the patient’s stay. The H-H-TCP case manager collaborates with the treating physicians and other members of the health care team to streamline the plan of care and to design and coordinate inpatient and follow-up care based on the comprehensive assessment and goals identified by the patient.

    Home Visits with Patients (By RN case manager & Physician)

    The H-H-TCP RN case manager visits each patient in his/her home the same day of discharge from the hospital. After the initial visit, a minimum of one home visit per week during the first month is made, followed by semi-monthly visits until discharge from the program. The H-H-TCP case manager makes telephone contact with the patient, as needed, and in each week an in-person visit is not scheduled. In addition, the nurse and assigned physician are available to the patients and their family/caregivers by telephone 24hrs a day. A house call physician also sees each Client within 24 hrs of hospital discharge. The house call physician will serve the patient as temporary primary care Physician until the patient is strong enough to be able to go out to see his/her office based PCP. The house call physician will effectively communicate and coordinate care with Patient’s PCP and all specialists during this transitional period.

    Trained Caregivers are assigned to the case.

    Our Case Managers identify and work closely with the patients and their loved ones who are willing to participate in the program. After patients are discharged from a hospital stay, they are assisted in the home by caregivers (few hrs/day or Live-In depending on the need) who can provide them with medication pick-up and reminders, assist with activities of daily living, household duties to keep their homes safe and clean and light homemaking and meal preparation. Caregivers also serve as the eyes and ears for family members and other loved ones to alert either doctors or family members if any notable situations arise.

    All Care Givers are thoroughly screened, extensively trained, insured and bonded, matched to your preferences, professional and reliable.

    American Care Partners @ Home is also an approved Service Provider (Private duty nursing, Respite care, Personal Care Services) for Various Virginia Medicaid Waiver Recipients Including:

    • ELDERLY or DISABLED with CONSUMER DIRECTED (EDCD)
    • TECHNOLOGY ASSISTED WAIVER SERVICES (for qualified patient on Home Ventilators, Tracheotomy, feeding tubes, etc…)

    LPNs and/or RNs are assigned as direct care givers for Patients with advanced and complex medical conditions (including those with In-home ventilator, tracheostomy, or on complex therapeutic regimens etc..)

    Transition from H-H-TCP

    At the end of the patient’s participation in H-H-TCP, the RN Case manager and the house call physician assures continuity of care and ongoing commitment to the patient’s self-management goals through communication with the primary care provider who will continue to follow the patient. A transition summary prepared by the H-H-TCP team leader is provided to patients and primary care providers. The patients’ goals, progress in meeting these goals and on-going or unresolved issues with the plan of care are addressed in these summaries. In some cases, the RN case manager will also help facilitate access to palliative care or hospice services, assisted living, or chronic case management, based on the individualized needs of the patient and his/her family.


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