Residential Care

DESCRIPTION

The Residential Care Program (RCP), as part of Nursing Home Services (NHS), provides home visits by nurse practitioners to patients who meet the criteria below.

• The patient remains on the Primary Care Physician (PCP) panel and the nurse practitioner partners with the PCP to provide optimal care.
• The nurse practitioner manages episodic and chronic health problems and has a tool kit of standardized tests and measures such as the Geriatric Depression Scale, Mini Mental, and a falls assessment for use as needed to complete a comprehensive assessment. The nurse practitioner orders diagnostic tests and medications, makes referrals to Home Health and Hospice or other services, and recommends/makes referrals to specialists.
• All clinical documentation is recorded in Epic.
• The nurse practitioner communicates with the PCP via Epic staff messaging and collaborates with the PCP to assure seamless delivery of care and services.

CRITERIA FOR RCP
• Generally, but not exclusively, the RCP patient is a frail adult, over age 65, on Medicare, medically complex, and has been identified by Outreach staff, Care Tracker’s Adult Family Home census, the PCP, or other GH provider as a frequent utilizer of urgent care/ED/acute care.
• Patient is unable to follow up with PCP, i.e., is somewhat homebound, although does not necessarily meet the Medicare Home Health definition of homebound.
• Patient may not have been seen in PC for more than one calendar year.
• Patient may have more than one chronic diagnosis such as CHF, COPD, or Diabetes.
• Patient may have advanced dementia, and be unable to be managed in the clinic setting.
• Patient may live in an Adult Family Home, in a private home, or in some cases in Assisted Living.

CRITERIA FOR RETURNING TO PCP FOR ONGOING CARE (RCP DISCHARGE CRITERIA)
Patient is able to follow up with PCP.

CRITERIA FOR ONGOING SERVICE WITH RCP
Patient has ongoing medical needs, but is unable to follow up with PCP.

HOW TO REFER TO RCP or CONTACT RCP

Send an Epic staff message to "p Nursing Home Services" providing:

(this is a dot phrase waiting to happen)

Patient name and consumer number
Reason for referral
Urgency of referral: within 72 hours within 2 months routine
Current address and phone number for the patient or DPOA

RCP GOALS:
• In partnership with primary care clinics, nurse practitioners make home visits to GH members residing in Adult Family Homes and other residences including the patient’s own home; this service enhances care and decreases visits to the ED, hospitalizations, and SNF stays.
• Improved quality measures, including HEDIS scores.
• Increased end of life planning.
• Patient and family satisfaction with the program.
• NHS and PCP satisfaction with the program.
• NHS nurse practitioner FTE adequate to serve this patient population.
• Increased revenue secondary to improved diagnostic coding.