Enhanced Home Support Models

By the end of 2022, BPP implemented nine Enhanced Home Support Models with the support of Baptist Primary Care, multiple specialty service lines, Baptist Home Health Care by BAYADA, clinical informatics, and BPP care coordination. These innovative models of care have substantially evolved since its first protocol for COVID-19. EHSMs aim to reduce utilization of hospital, emergency department, and skilled nursing facility services by safely managing patients in the home setting.

A physician can order the EHSM standing orders for patients who meet qualifying criteria, which depends on the protocol details. For example, a patient with heart failure (HF) can be referred to the HF EHSM from primary care, the emergency department, or the inpatient setting. On the contrary, a patient with sepsis may only be referred to the Sepsis EHSM by a hospitalist in the inpatient setting as this protocol is intended for patients who had a hospitalization for an episode of sepsis.

The success of the EHSMs can be attributed to Baptist Health’s post-acute preferred provider network, or PPN. The PPN is a network of home health agencies and SNFs specializing in post-acute care who work closely with Baptist Health to provide safe, high-quality care. To date, there are six home health care agencies and 11 skilled nursing facilities in the PPN. Success can also be attributed to the inpatient care coordination team who ensure that our patients transition to the most appropriate next site of care, in addition to physicians who refer patients to these home-based models.

Patient Experience

Enhanced Home Support Models

Joan Kavanaugh takes medicine twice a day for atrial fibrillation (AFib). As a component of her clinical care plan, the 86-year-old monitors her blood pressure and pulse. When a recent reading detected tachycardia, Joan’s daughter, Mary, immediately became concerned.

“My mother was not acting quite right, so I called her Baptist Health care coordinator right away,” Mary said.

Kathleen Ostynski, BSN, RN, an ambulatory care coordinator with Baptist Physician

Partners, made a quick assessment of the situation over the phone.

Following a focal neurologic and respiratory survey, she determined Joan displayed neither dysarthria or dyspnea. She and Joan’s daughter developed a quick action plan that included:

• Calling 911 so emergency medical technicians could further assess Joan to determine if she needed additional medical attention

• Purchasing a pulse oximeter at their nearest drug store to more reliably track her heart rate

• Scheduling a home visit by Baptist Home Health Care by BAYADA

During the home health visit, the nurse, Sharon, determined Joan’s vital signs were normal. She didn’t need further medical evaluation at the Emergency Room.