Next up in the news is a look at how we can use a multi-disciplinary care team approach to managing homebound patients and reducing their hospital readmissions and length of stay when they do get admitted. Researchers at Hofstra University in New York presented on their Advanced Illness Management (AIM) program at the recent annual meeting of the Society of General Internal Medicine.

5% of Patients – %50 of Health Costs

homecare-nurse-patient-education-medication-smAccording to the study, the goal of the team approach is to reduce the so-called “frailty gap” in patients who are homebound for multiple, complicated, co-morbid conditions. The patients in the study, while accounting for only 5% of the total health system patient population, cost the system 50% of the total spent on healthcare before the study.

The stated goals of the AIM program were to change the number of hospital admissions, reduce length of stay, improve patient/care team communications, patient satisfaction, and discharge medication reconciliation. According to the study’s authors, the AIM program reduced hospital admissions by 37% and hospital stays by 1.5 days when they were readmitted.

Multidisciplinary Healthcare Team

The team for the AIM program included a group of doctors, nurse practitioners, nurses, care coordination administrators and social workers and followed the patients over the course of a year. During that time, their patients actually got sicker because of the progressive nature of their chronic illnesses but they still reduced readmissions and length of stay.

I think that this points to another success in adjusting the way we’ve “always done things” in healthcare. We used to just put these types of patients in a revolving door of care at the hospital without any real change in their care, satisfaction or overall health condition. I truly believe these patients are happier at home than in the hospital.

Make sure you check out the link in the show notes for this study and also that you let me know when your hospital system is doing something similar so I can share it with other members of the Nursing Show community. Remember that you can always email me here at I look forward to hearing from you.

Make sure you follow-up on the links for this news item and all of the other news and additional resource links from this week’s episode – Public Health Digital Disease Detection Tools and Episode 294.



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