Despite the growing body of evidence that supports the efficacy of at-home care for patients who would otherwise be hospitalized at higher cost and at greater risk for infection, innovative health systems pursuing this care model do have to make up for some wild cards when caring for folks at home.
One example: Whatever else one might say about the good and bad of hospital rooms, there is rarely a polyglot assemblage of prescription medicines lying around that, if taken, could pose a risk to the patient. Yet that is precisely the reality in the homes of patients, especially those who are 65 or older.
That is why in its primary care at home program, New Jersey-Based Atlantic Health System conducts a “medicine-cabinet autopsy,” in the words of Brenda Matti-Orozco, MD, an internist and hospice and palliative medicine physician at Atlantic Health System.
“The initial visit is really spent doing a comprehensive assessment,” said Dr. Matti-Orozco. “We include a home safety check looking at the environment outside and inside the home. We do what is called a medicine-cabinet autopsy, looking for all the medication and pill bottles in the home. We look into their pantries and their refrigerators. … It's like a box of chocolates. You never know what you're going to get.”
Atlantic Health System has offered remote monitoring for patients through Atlantic Visiting Nurse since 2004, but few people in the area were aware of it at first.
Meanwhile, a need for remote care was lurking around the corner with the COVID-19 pandemic. More patients needed direct and comprehensive health care outreach to help manage conditions they had prior to the pandemic, along with a new set of health challenges.
In 2019, Atlantic Visiting Nurse launched a new platform for remote patient monitoring (RPM), which aimed to streamline onboarding and monitoring of patients who are at an increased risk of hospital readmission. Then, in 2022, Atlantic Health System launched a primary care at home program that eliminates the need for patients to travel long—and potentially prohibitive—distances to see their physician for routine care.
Atlantic Health’s primary care at home program served 750 patients in 2023, and leaders of the effort estimate that 1,000 patients will be served by the end of 2024. With the Atlantic Visiting Nurse RPM program, 1,400 patients were on home monitoring in 2023, with up to 160 patients being served and monitored each day.
“It was very helpful during COVID when patients were more resistant to people coming into their homes. We were able to connect with them when they felt isolated,” said Dr. Matti-Orozco, who is also section chief for general internal medicine and palliative medicine at Morristown Medical Center.
Atlantic Health System is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Atlantic Visiting Nurse offers skilled nursing, physical therapy, occupational therapy, registered dietitians, speech therapy, social work consultations and remote-patient monitoring for home bound patients. Patients considered high-risk for readmission to the hospital—such as those with cardiopulmonary conditions—are enrolled into the RPM program and sent a kit that allows them to measure their vital signs every day, including weight, blood pressure and oxygen level. Also, patients complete a survey about symptoms to share how they are feeling.
“RPM nurses review the vital signs daily and outreach patients who transmit abnormal readings or report negative symptoms. Abnormal readings are escalated to the patient’s physician if indicated. Our goal is to prevent readmissions to the hospital,” said Jennifer Dwyer, assistant manager of the remote-patient monitoring for Atlantic Visiting Nurse. The program shines when we can educate patients on how to manage their chronic conditions. We meet the patients where they're at and work to keep them at home, happy and healthy.”
“When we talk about the overall aim right now for health care, we're going towards value-based care,” said Dr. Matti-Orozco. “It's providing the right care at the right time, at the right place ... so that the patient really feels supported. And it’s a way to prevent nursing home placements for seniors.”
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Covering a range of patient needs
Atlantic Visiting Nurse covers six counties in Northern New Jersey and patients with a cardiopulmonary condition and enrolled into the remote patient monitoring program. Meanwhile, Morris County, New Jersey, residents who are 65 or older can qualify for Atlantic’s primary care at home initiative.
With RPM patients, there is more of a concentration of patients with a diagnosis of heart failure, chronic obstructive pulmonary disease, “pneumonia, COVID, and also patients who've recently had cardiac surgeries or poorly controlled hypertension,” said Dwyer.
Preventing readmission after a hospitalization remains a primary goal, so the program also involves educating patients about what they can better do from home to manage as much of their care as possible. Offering a higher level of support is essential to meeting this objective.
Atlantic Visiting Nurse team members also factor in who is checking in on the patient and what services they may already have, as well as whether they are effective. They also assist the patients in setting up the RPM kit and submit their vitals, which can be a challenge for people who aren’t tech savvy.
Once that is accomplished, “we're monitoring them for the length that they're on home care. That can be 30 to 60 days depending on their home care goals,” Dwyer said, noting “we monitor them seven days a week, 8 a.m. to 4 p.m., collaborating with physicians who see those patients.”
Keeping patients out of the hospital
Through the health system’s visiting nurse, home monitoring and primary care at home, improvements continue to be made in reducing hospital readmissions.
“We are refining our data collection for our dashboard, but by and large, we're able to focus on the key quality and outcome measures that are also aligned with the system goals. And we’ve received good feedback from patients and families,” said Dr. Matti-Orozco.
Plans are in place to expand both programs to reach more patients in a sustainable manner.
“Home is where the heart is, and it's where we all eventually want to be,” said Dr. Matti-Orozco, noting that older patients “who become vulnerable to nursing-home placements are the ones who have not been able to keep up their relationships with their primary care physicians because they're no longer able to come to the office.
“It's a way, also, for us to support caregivers because we care not just for the patient, but also for the caregivers” who are under so much strain, she added.
“I hear from a lot of overwhelmed caregivers who express that ‘I'm not a doctor, I'm not a nurse. I don't know what I'm doing,’” Dwyer said. For caregivers especially, “having that support in their own environment is so beneficial.”
In related policy, the AMA signed a letter requesting an extension of the Acute Hospital Care at Home Waiver (PDF) for five years. Ten AMA Health System Program members also signed on to the letter.
