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At-Home Support Helps Patients Better Manage Health Risks

Family Health Centers at NYU Langone has launched Primary Care Plus, a program that provides at-home support to patients who are at risk for being hospitalized unnecessarily.

The Primary Care Plus collaborative care team includes a physician, a nurse practitioner, a social worker, and community health workers. The team visits patients at home to get a better understanding of the medical and social barriers to care and to determine the best way of addressing these barriers.

“Many patients are unable to travel to a clinic, do not adequately understand their care plans, or have insufficient resources or support, which can be difficult to identify and address in the hospital or a doctor’s office,” says program director Ramiro Jervis, MD, who joined Family Health Centers at NYU Langone in July 2018. “There’s growing evidence that home visit-based interventions lead to better health outcomes, are cost-effective and lead to fewer hospital admissions.”

Primary Care Plus is funded through a grant from NYU Langone Brooklyn Performing Provider System (PPS), which participates in the Delivery System Reform Incentive Payment Program (DSRIP), an initiative of the Centers for Medicare and Medicaid Services and administered by the New York State Department of Health. It is not limited to patients who are homebound and who are Medicare beneficiaries. Enrolled patients are treated for conditions such as heart disease, diabetes, or lung disease.

“A person’s health is determined by what happens in the home and in the community, not necessarily in the doctor’s office,” says Larry K. McReynolds, executive director of Family Health Centers at NYU Langone and executive sponsor of the NYU Langone Brooklyn PPS. “By bringing doctors to where patients live, we can bring the right level of care to the patient in a familiar setting prior to the illness escalating, and thus requiring care in a medical setting.”

Encouraging Patients to Actively Participate in Their Care

According to Dr. Jervis, a common challenge of complex care management programs is low patient engagement, but from August 2018 through December 2018, Primary Care Plus has managed to increase patient engagement by more than 75 percent. Moreover, recent data show that enrolled patients have 40 percent fewer hospital days in the six months after enrollment compared with the six months before enrollment.

Patients often suffer from multiple health issues—high blood pressure, heart issues, asthma, chronic obstructive pulmonary disorder, and diabetes, which can be further complicated by substance use disorder. In one particular case, hospitalizations were reduced from seven in each of the last two years before enrollment in the program to one admission, reflecting a significant improvement in patients’ health and compliance with the recommended treatment regimen.

At-home visits from the Primary Care Plus team allow an evaluation not only of a patient’s medical condition, but also an assessment of a patient’s living conditions. Together with a nurse practitioner and community health workers, Dr. Jervis visits patients in their homes as often as needed until they are able to self-manage and return to their usual primary care team. Patients have direct access by telephone to Dr. Jervis and other team members. The ability to directly communicate with the Primary Care Plus team has been key to its success in helping patients avoid unnecessary hospital stays.

Approximately 135 patients, ages 40 to 90, have already participated in the program. Participating patients include a mix of people who pay through Medicare or Medicaid, as well as a small number who have commercial insurance.

With the five-year DSRIP initiative slated to end in 2020, Family Health Centers at NYU Langone is determined to continuing the program.

“We believe that there is enough patient need to justify continuing Primary Care Plus through a combination of fee-for-service activities and shared savings from managed care contracts,” says Isaac Dapkins, MD, chief medical officer of Family Health Centers at NYU Langone.

The Family Health Centers at NYU Langone is one of the nation’s largest federally qualified health centers. The health center plans to further analyze the effects Primary Care Plus has on the outcomes and readmissions of enrolled patients versus similar unenrolled patients.

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Colin DeVries

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