Traditionally, hospitals excel at treating a patient for an episode of care- a heart attack or surgery, for example. A new trend - population health management - attempts to improve quality and reduce costs. A key strategy is influencing what happens before and after an acute episode, especially for those whose chronic illness might be more effectively managed outside hospital walls. Partners HealthCare at Home is a key player in this trend.
One model is the Partners Mobile Observation Unit (PMOU) program, an initiative created by PHH and Partners Population Health Management (PHM) to help reduce hospitalizations. The program was launched in June 2013 as a pilot at MGH where the team works closely with physicians in the ED and Observation Unit (OBS), as well as the Case Management and Integrated Care Management Departments. Dana Sheer, NP, PHH, oversees the program with assistance from PHH nurse practitioners. PMOU operations are funded by PHM and the program will be expanding to other locations this coming year.
The goal is to identify patients who are admitted to the ED with symptoms of an illness or injury that can be cared for at home with immediate follow-up by a home care provider (e.g. a nurse or nurse practitioner). Although many home care agencies are working on getting patients quicker access to services after a visit to the hospital, this pilot goes beyond that, bringing a clinician with advanced skills into the home to directly assess what each patient needs.
“I’m an acute care nurse practitioner, so during that critical period of transition from the ED to the home, I provide a more intensive, structured visit and higher level of coordination and communication,” says Dana. “No question, an acute hospitalization can be a turning point in a patient’s life, but for many it’s a nanosecond in the whole spectrum of what happens. We need to see where and how the patient lives to know what will make a difference between following the treatment plan and failing at home. What kind of support is there in the home? Does the patient/family understand medications? We want to identify how to intervene before they need a hospital stay.”
Based on her findings, Dana can collaborate with the ED to augment the medical plan, and then coordinate with the primary care physician about follow-up care. If the patient needs monitoring over the next few hours, one of the pilot project nurses takes over so that Dana can assess the next patient. The team also facilitates connection with PHH or the patient’s preferred home care provider and other community resources to address ongoing needs. There is no charge to the patients participating in the pilot project.
For more information about the program, please contact Dana Sheer, NP at firstname.lastname@example.org.