Nurse practitioners in home-based prepalliative care demonstrate an innovative, value-based approach to end-of-life care planning.

BACKGROUND: Nurse practitioners (NPs) demonstrate value-based, home-based primary health care (HBPC) to home-bound patients with high disease burden at reduced cost. PURPOSE: The research questions were as follows: (a) Does patient-centered, prepalliative care delivered by HBPC NPs decrease number of hospitalizations and emergency department (ED) visits and increase patient satisfaction? and (b) What are the criteria for patients to receive end-of-life (EOL) discussions by NPs? METHODOLOGY: This was a quasi-experimental, retrospective two-group design with a convenience sample of 233 HBPC patients from an academic clinical partnership compared with 234 clinic patients matched on age and Charlson Comorbidity Index (CCI) score over 4 years. Measures included signed advanced directives (ADRs), medical orders of life-sustaining treatment (MOLST) forms, number and length of home visits, hospitalizations, and ED visits after diagnosis. Chi-square analyses and general linear models using a Poisson distribution were conducted. RESULTS: Home-based primary health care patients had higher disease burden, statistically higher CCI scores, and signed ADR and MOLST agreements more often than clinic patients with significantly fewer hospitalizations and ED visits, and longer visits with providers. CONCLUSIONS: Patients receiving HBPC for prepalliative, EOL illness benefit from more time to discuss the difficult factors surrounding access to care for those with life-threatening illnesses. IMPLICATIONS: Recipients of prepalliative HBPC by NPs could require fewer provider visits, hospitalizations and ED visits, patient satisfaction, and a potential decrease in health care spending at EOL.

Use of social determinants of health codes in home-based primary care.

BACKGROUND: The Affordable Care Act created funding for nurse practitioner education programs to transform the primary health care workforce through student awareness of how social, political, economic, and environmental factors influence individual and population health. Funding established Academic Clinical Partnerships (ACPs) that created value-based health care models, which improved patient outcomes and decreased hospital and emergency department admissions and health care costs. The ACP established a home-based primary health care (HBPC) program to deliver primary care and collect patient data. PURPOSE: The purposes were to describe the incidence of chronic conditions for HBPC patients and determine associations between chronic conditions and presence of social determinants of health (SDoH). METHODOLOGY: Nurse practitioner students were assigned to HBPC clinical placements. A convenience sample of 102 high-risk, homebound patients was identified. Nurse practitioners and students recorded deidentified patient data, including ICD-10-CM codes into a Health Insurance Portability and Accountability Act compliant platform. Secondary analysis of patient records assessed for SDoH through Z codes. RESULTS: Patients had high incidences of hypertension, diabetes, pulmonary disease, heart disease, chronic pain, mood, and substance abuse disorders. Secondary analysis revealed that 92% of patients had indications for the use of Z codes, but these were not recorded. CONCLUSIONS: Common Z codes were personal risk factors, housing/economic circumstances, care provider dependency, lifestyle, and family support. IMPLICATIONS FOR PRACTICE: By coding for SDoH, providers and agencies can realize higher reimbursement rates in HBPC settings. Nurse practitioners can use this information to provide better treatment recommendations, more accurate diagnoses, and referrals to enhance primary care services to a patient population negatively affected by SDoH.