Michigan HouseCalls launches in-home transition of care service to improve patient access, decrease hospital readmission

Members of the HouseCalls team.

Patients are particularly vulnerable when moving between levels of care. Transition of care (TOC) visits help to safely bridge these transitions. Such visits seek to decrease communication breakdowns, clarify medication changes and other discharge instructions, identify gaps in care and assess social determinants of health.

Ideally, these critical visits are conducted by the primary care provider in the clinic, however many patients face barriers to access which make in-clinic visits difficult and sometimes impossible.

Michigan Medicine’s HouseCalls program has recently launched an initiative to bring this service to patients who face such barriers. The program is designed to improve access to care by providing the option of an in-home TOC visit to patients with severe illness, debility, mobility issues and/or limited or no access to reliable transportation.

To qualify for this service, patients must be at least 18 years of age, be under the care of a Michigan Medicine primary care provider (PCP) and live in Washtenaw County.

Initial contact with the patient should be made by a member of the PCP team within 24-48 hours of hospital or subacute rehabilitation facility discharge. If barriers to timely care are identified, a referral may be placed to the HouseCalls program. Once received by the HouseCalls team, the referral will be reviewed and, if appropriate, an in-home TOC visit will be scheduled within 7-14 days of discharge date based on patient complexity.

During the in-home TOC visit, providers are able to review medications and address changes in real time, educate patient and families regarding symptom recognition and action plans to avoid unnecessary emergency department visits. The HouseCalls program will provide a focused assessment designed to augment understanding of the patient’s home environment and its potential effects on health, well-being, treatment compliance and acute care utilization and identify such factors for the primary care team to address. The completed assessment and recommendations will be routed to the patient’s primary care team within two business days.

If long-term needs are identified, a referral may be made to the HouseCalls Care management team to assist with resource finding, overall care coordination and urgent visits at home while the patient has decreased access to the clinic.

To refer a patient to Michigan HouseCalls, simply place an order for “House Calls” in MiChart and follow the prompts. If you have any questions, please contact Latechia Howard at 734-477-7256.