New research on patients recently hospitalized for sepsis (a life-threatening response to bacterial infection) by VNSNY’s Center for Home Care Policy & Research shows that early home visits by a nurse, combined with at least one visit to a physician during the first week after discharge, significantly reduced their likelihood of being re-hospitalized. The study, published in the journal Medical Care, found that sepsis survivors who received a first nursing visit within two days of hospital discharge plus at least one additional home visit in their first post-hospital week, and who also saw a doctor in that first week, reduced their probability of 30-day all-cause readmissions by seven percentage points.
“With one million sepsis patients being discharged annually in the U.S., many of whom end up being readmitted, this finding has big implications,” notes study co-author Kathryn Bowles, PhD, van Ameringen Chair in Nursing Excellence at the University of Pennsylvania and Director of VNSNY’s Research Center. Dr. Bowles points out that the combination of front-loaded home nursing visits and a prompt doctor’s appointment is critical, since neither intervention produced improvements on its own. The study also stresses the importance of having the hospital or home care team schedule the patient’s first post-discharge doctor’s visit, to ensure that it takes place—rather than leaving this up to the patient.
This VNSNY study adds to a growing appreciation of home care’s key role in preventing infection-related hospitalizations. As part of its own sepsis management efforts, VNSNY has instituted a sepsis awareness program for its home care clinicians—including a sepsis screening tool that is embedded in patients’ electronic medical records. Additionally, VNSNY is training its home health aides (HHAs) to monitor high-risk patients for signs such as fever, confusion and rapid heart rate that might indicate the onset of systemic infection.
“Our clinicians in both VNSNY Home Care and Partners in Care are now utilizing the face-to-face Home Care Association Sepsis Tool on every home visit, while other departments are routinely utilizing telephonic sepsis screening tools to check patients for potential sepsis,” says Joan Cassano, VNSNY’s Vice President for Population Health and Care Management. If a patient’s score on the screen is problematic, the VNSNY clinician immediately contacts the patient’s doctor and either arranges for a same-day appointment or has the physician write a prescription on the spot for a broad-spectrum antibiotic.
Similarly, in VNSNY’s new Care Management Organization (CMO) program for high-risk insurance plan members, if a sepsis case is suspected a nurse practitioner can be dispatched that same day to assess the patient in their home. The CMO has also rolled out a new remote patient monitoring program that allows patients to transmit data to their VNSNY care manager daily, including possible signs of sepsis, and high-risk patients also have the ability to conduct a face-to-face virtual encounter with a CMO nurse practitioner.
“This is about protecting our patients’ and plan members’ health and keeping them safe at home,” says Cassano. “Besides being a potentially fatal condition, sepsis is one of the leading causes of hospital readmissions. The bottom line is that if a VNSNY patient or member has any infection risk at all, our home care providers need to be ready to act immediately.”