Newswise — As part of an innovative program aimed at reducing unnecessary emergency room visits and hospital stays, teams comprised of a paramedic, critical care nurse and EMT have begun making house calls on heart patients soon after their discharge from The Valley Hospital in Ridgewood, NJ.
“Patients with cardiopulmonary disease, particularly those with heart failure and chronic obstructive pulmonary disease, are particularly vulnerable to re-hospitalization, especially during the transitional period after they first arrive home,” said Lafe Bush, a paramedic and director of Emergency Services at Valley. For example, the 30-day readmission rate nationwide for patients with heart failure is nearly 25 percent, and the majority of readmissions occur within 15 days of hospitalization, according to a study of Medicare data published last year.
Valley’s Mobile Integrated Healthcare Program brings together Valley’s Department of Emergency Services and Valley Home Care to provide proactive, post-discharge home checkups to try to whittle these numbers down. The program, which launched in August 2014, targets those patients with cardiopulmonary disease at high risk for hospital readmission who either decline or do not qualify for home care services. The team provides a full assessment of the patient, including a physical exam, a safety survey of the patient’s home (focusing on fall risks), medication education, reinforcement of discharge instructions and confirmation that the patient has made an appointment for a follow-up visit with his or her physician.
“This population of chronically ill patients, who are generally elderly, have frequent bounce-backs to the hospital, which we know is not good for them,” said Robin Giordano, supervisor of Valley’s Outpatient Transitional Care Program, which provides multidisciplinary care coordination for patients with heart failure.
The program initially targeted patients with heart failure, but has recently been expanded to include patients who have undergone the transcatheter aortic valve replacement (TAVR) procedure, a minimally invasive treatment option for patients with severe, symptomatic aortic valve stenosis, for whom traditional valve replacement surgery is not an option. “These patients also tend to have a high rate of readmission to the hospital,” Bush said.
“Our TAVR patients often have multiple health problems, and their postop care can be very complex,” said Mary Collins, Supervisor of Cardiothoracic Surgery and the Cardiovascular Screening Program at Valley. “This unique service offers an advantage to these patients who are not only recovering from their heart valve procedure, but also must continue to cope with and manage their existing health problem. Early clinical assessment and appropriate intervention prevents complications and allows these patients to continue to recover at home.”
The Mobile Integrated Healthcare Program complements Valley Home Care’s comprehensive roster of services, which include skilled nursing care, a telemanagement program, rehabilitation therapy, cardiac home care, Valley Hospice, certified home health aides, diabetes support services, and hospital-to-home care coordination and more.
“Our service is a one-time home visit to make sure the patient is on the right path and guide him or her to the next step,” Bush said. “It’s part of Valley’s overcall continuum of care.”
This is the latest in a number of programs Valley has put in place to reduce readmissions. The hospital’s comprehensive outpatient heart failure program — Outpatient Transitional Care — is designed to keep heart failure patients functioning in their homes and community and to keep them out of the hospital. “Most of our patients are elderly and have many other medical problems,” said Valley Medical Group’s Kariann Abbate, M.D., a board-certified cardiologist in advanced heart failure. “We like to use a holistic approach with our heart failure patients.”
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