Characterizing the high-risk homebound patients in need of nurse practitioner co-management

Abstract

By providing more frequent provider visits, prompt responses to acute issues, and care coordination, nurse practitioner (NP) co-management has been beneficial for the care of chronically ill older adults. This paper describes the homebound patients with high symptom burden and healthcare utilization who were referred to an NP co-management intervention and outlines key features of the intervention. We compared demographic, clinical, and healthcare utilization data of patients referred for NP co-management within a large home-based primary care (HBPC) program (n=87) to patients in the HBPC program not referred for co-management (n=1027). A physician survey found recurrent hospitalizations to be the top reason for co-management referral and a focus group with nurses and social workers noted that co-management patients are typically those with active medical issues more so than psychosocial needs. Co-management patients are younger than non-co-management patients (72.31 vs. 80.30 years old, P<0.001), with a higher mean Charlson comorbidity score (3.53 vs. 2.47, P=0.0001). They have higher baseline annual hospitalization rates (2.27 vs. 0.61, P=0.0005) and total annual home visit rates (13.1 vs. 6.60, P=0.0001). NP co-management can be utilized in HBPC to provide intensive medical management to high-risk homebound patients.

Patient house calls in Attica and Thessaloniki, Greece (2005-2015): a model for out-of-hospital multispecialty emergency medicine

“…In most countries of the developed world, several companies or organizations (including hospitals and insurers) offer house-call visits mainly by general practitioners and family physicians; other services can include nurse practitioners (an increasingly used service in the USA), nurses, social workers, psychologists, or a multidisciplinary approach providing care with 2 or more of the aforementioned professionals [ 19 , 20 ]. In contrast to the worldwide practice, the SOS network in Greece offers house-call visits by specialists.…”

Prevalencia de personas mayores confinadas en su hogar en España

“…Este conjunto de personas tiene escasa visibilidad social por haber sido poco estudiado este asunto y por la propia naturaleza de sus problemas de movilidad física, que limitan gravemente el contacto con el exterior y les impiden beneficiarse de las ventajas de vivir en sociedad. Además, suelen precisar intensamente asistencia personal y servicios sociales y sanitarios 1 . Por ese motivo, conocer su prevalencia ayudaría a organizar de forma adecuada los servicios sociales y sanitarios de atención que repercutan positivamente en su calidad de vida.…”

Integrated older people care and advanced practice nursing: an evidence‐based review

“…Coordinating care for individuals Improved delivery of care was achieved through coordination of services in the US and Thailand. An NP co-managed programme provided medical management, post-discharge visits and care coordination thus, improving patient transition and provider satisfaction (Jones et al 2017a;Jones et al 2017b). Thai studies focused on coordination of village health volunteers and community workers in dementia care and promoting self-care among the elderly (Samantarat 2015;Wanthanatas 2017).…”