Missouri Foundation for Health Grant Helps with Hospital Readmissions

House calls have returned for some Texas County Memorial Hospital patients thanks to an $110,567 grant from the Missouri Foundation for Health (MFH).

The MFH grant specifically targets chronically ill patients that have been inpatients at TCMH. Certain patients will qualify for a home visit from the TCMH healthcare provider following the patient’s discharge from the hospital with the hope of keeping the patient from being readmitted to the hospital within a short amount after discharge.

The grant funds will be divvyed out over the next three years to pay the wages and travel expenses of a TCMH healthcare provider, to purchase a portable ultrasound unit and a defibrillator, to provide additional critical care education and to pay for patient care supplies needed for patients in their home.

“Missouri Foundation for Health has a special projects funding opportunity available for grants like this one,” Jay Gentry, TCMH Healthcare Foundation director, said. Gentry pursued the grant on behalf of TCMH.

Based in St. Louis, MFH is an independent philanthropic foundation dedicated to improving the health of the uninsured and underserved in the region. TCMH has received grants for other project in the past.

“The goal of the project is to make 150 home visits per year, and decrease the number of readmissions of chronically ill hospital inpatients,” Gentry said.

The focus of the grant is on chronically ill Medicare patients with cardiopulmonary issues, but other classifications of patients are identified at TCMH and cared for in the home, too.

Statistics show that half of all Americans have a chronic illness, and 25 percent of persons with a chronic illness have more than one chronic condition. Chronic conditions include heart disease, diabetes, asthma, obesity and high blood pressure.

For many years, TCMH has been collecting data on hospital patients and hospital readmissions, and the information is reported to the Center for Medicare Services (CMS). Annual Medicare reimbursement levels at hospitals are based on a number of different criteria specified by CMS, including readmissions of hospital patients.

“Many of the inpatients at TCMH have multiple chronic conditions, so the potential readmission rate is high,” Gentry said.

Statistics show that chronically ill hospital inpatients have the most likelihood of readmission to the hospital within the first three days after discharge from the hospital.

“Following up with the patient in his or her home after they are discharged from the hospital is one way to slow or cut readmissions,” Gentry explained.

Candidates for the house calls are identified during their inpatient stay at TCMH.

Mary Barnes, a registered nurse overseeing case management at TCMH, and Angie Gimpel, social worker at TCMH, follow each patient’s hospital stay. They use a scoring tool that helps them determine if a particular patient is a candidate for follow up care in the home.

The scoring method takes into account the chronic conditions a patient has, how long the patient has been hospitalized, whether the patient in an inpatient or observation patient, and the number of emergency room visits by the patient in the last six months.

Patients that score 90 to 95 percent with the scoring tool are targeted for home visits. Barnes or Gimpel will connect with the patient asking him or her if a home visit would be okay after they are discharged from the hospital. When a patient approves the home visit, Chip Lange, physician assistant at TCMH, is contacted about making the home visit following discharge.

Lange tries to connect with his home visit patient prior to their discharge from the hospital.

“I try to give the patient a face to put with the name before I make the home visit,” Lange said. “Plus, if I see them before they go home, I have the opportunity to assess how they look and sound before they leave the hospital which gives me a baseline for their health when I see them in their home.”

Lange has already started seeing patients in their homes, a process he describes as going “very well”.

A typical home visit takes place 24 to 72 hours after the patient is discharged from the hospital. Lange noted that the most critical time for a patient’s readmission to the hospital is within the first three days of discharge.

Lange does a physical assessment of the patient, provides medication information and instructions, follows up with discharge information and assesses the patient’s home to determine if other resources such as a walker or home health are needed to improve the patient’s health and safety at home.

“A much more complete picture of the patient is available when you visit their home,” Lange said, adding that the patients he has visited at home like having Lange “on their turf”.

“There’s a lot less pressure for the patient because they aren’t worried about getting to the appointment on time, finding a ride to the appointment or the other stresses of leaving the home for an office visit,” Lange explained.

Lange noted that in addition to the comfort the patients find from the home visit, he’s able to spend whatever time is needed with the patient getting a clear look at the patient’s medications and the administration of the medication.

“The home visit is much more slow-paced, and we usually have pretty good discussion about the patient’s health,” Lange said.

The grant allows TCMH to make home visits to chronically ill inpatients following their discharge throughout the TCMH service area. The grant targeted Medicare patients at TCMH, but any patient that meets the criteria is eligible.

Jean Freeman-Crawford, program officer for the Missouri Foundation for Health, presented a ceremonial check to Texas County Memorial Hospital for the house call grant for chronically ill patients. Shown with the check are (left to right) Chip Lange, physician assistant at TCMH; Wes Murray, TCMH CEO; Freeman-Crawford, and Jay Gentry, TCMH Healthcare Foundation director.