Evaluation of a Home-Based, Nurse Practitioner-led Advanced Illness Care Program

Area of Science:

• Gerontology and Palliative Care
• Health Services Research
• Chronic Disease Management

Background:

• Patients with serious illness in the U.S. often face fragmented care due to mobility issues, social support needs, and complex comorbidities.
• Existing care models may not adequately address the palliative care needs and coordination challenges for this population.
• The Advanced Illness Care (AIC) Program was developed to provide home-based, nurse practitioner-led care for individuals with serious or complex chronic illnesses.

Purpose of the Study:

• To evaluate the impact of the AIC Program on hospital encounters, including hospitalizations and emergency department (ED) visits.
• To assess the effect of the AIC Program on hospice conversion rates.
• To determine the influence of the AIC Program on patient mortality within specified timeframes.

Main Methods:

• A retrospective nearest-neighbor matching design was employed.
• Patients enrolled in the AIC Program were matched to fee-for-service Medicare controls based on demographics, comorbidities, diagnosis-related group, and home health enrollment.
• Outcomes measured included 30- and 90-day hospital encounters (ED visits and hospitalizations), hospice conversion, and mortality.

Main Results:

• AIC enrollees showed a higher likelihood of ED visits at 30 and 90 days compared to controls.
• AIC enrollees had a decreased likelihood of hospitalization at 30 days.
• A significantly higher likelihood of hospice conversion was observed among AIC enrollees (22.4 percentage points).

Conclusions:

• The AIC Program delivers essential care coordination for home-based patients with serious illness.
• Early identification and management of care needs by the AIC Program may help avert unnecessary hospitalizations.
• The program facilitates timely access to hospice services for patients nearing the end of life.