Making an impact with high-risk patients

Liz Vasquez, FNP-BC, was just making conversation when she asked about her patient’s Thanksgiving plans. Instead, that one question changed their routine home visit. The discussion turned from arthritis and inflammation into a deep dive about the patient’s lifelong, undisclosed social anxiety.

“Even though she had six children — several who were physicians — she said she wasn’t going to have them over for the holiday,” said Vasquez, a family nurse practitioner who works closely with Primary Care IPA in Buffalo, NY. “Suddenly, she opened up about her anxiety. We talked for over an hour about how she had struggled with it her entire life. She’s in her late 80s but had never felt comfortable talking to anyone about it.”

Vasquez jumped into action and connected her patient with a counselor. And, now, the senior woman feels more at ease and often calls Vasquez to discuss her anxiety.

Moments like this inspire Vasquez — and other advanced practice providers (APPs) like her — to work as a nurse practitioner with Honest Medical Group and support a mission committed to delivering value-based care. Each visit is an opportunity to make a difference in a patient’s life and further assist doctors who in many cases are in desperate need of support, too.

Meeting patients where they are

Like most people, patients who receive care visits in their home may see their doctors once or twice a year. However, these individuals often have other health concerns that demand additional monitoring and care. And many face mobility or transportation obstacles that make it difficult for them to get the care they need, when they need it – and where they need it.

This is where APPs, like nurse practitioners, play a valuable role in supporting patients. They help individuals manage their chronic conditions and assess their current health status between visits to their primary care provider (PCP).

“We see the patients that doctors and insurance providers identify as being at high risk for chronic co-existing conditions, hospitalizations, and poor outcomes,” says Marcy Binford, APRN, AGACNP, a family nurse practitioner who works in partnership with practices from MedNetOne Health Solutions throughout Detroit and southeast Michigan.. “By seeing these high-risk patients in a home setting, we ensure their wellness and acute care needs are met.”

During a 15-minute office appointment, providers only see and hear what patients want them to know. However, home visits present a more real-world and holistic view of a patient’s health status. These crucial interactions show where nurse practitioners can help improve someone’s quality of life, Vasquez says. APPs learn the factors influencing well-being, such as nutrition, cleanliness, or family support.

“When you’re in a patient’s home, you see the entire picture of what really goes on in their lives,” she says. “Patients share more with you when they feel comfortable in their own space.”

In fact, patients are more likely to reveal whether they’re taking their medication properly during a home visit, says Amy Baun, FNP-BC, a family nurse practitioner working alongside practices from Catholic Medical Partners in Buffalo. Accurate medication management information is vital. Taking medicine incorrectly can cause adverse effects and make a person feel ill or worsen their condition.

“I frequently see that patients tell their doctors they’re taking their medication when they aren’t,” Baun says. “Maybe they forget, maybe they don’t like the side effects, or maybe they simply can’t afford it. Part of my job is helping them figure out ways to manage their medication so they can feel better.”

Vasquez says that building a trusted relationship with every patient is the most significant impact APPs have. It’s also one of the biggest motivators behind why these providers embrace their work.

“Most patients love that someone can come into their homes on behalf of their doctor’s office,” she says. “They appreciate that we truly understand their medical history, that we take the time to go through all the issues affecting them, and that we will follow up to see how they’re feeling – as well as work with their doctor.”

Collaborating for improved care

Amy, Liz, and Marcy all echo that even though they may be going into homes alone, they really enjoy the team-based approach that bolsters their ability to provide at-home care in a value-based system. APPs serve as an extension of the patient’s PCP office and collaborate directly with the PCP — often in real-time while during the visit.

Nurse practitioners function as the doctor’s eyes and ears, gathering the most current information about a patient’s condition during each visit, Baun says.

If a patient is experiencing an acute health concern, the nurse practitioner can immediately communicate with the PCP through a secure messaging platform, ensuring both providers are aligned with the diagnosis and treatment options. It’s a capability and process that reinforces the trust between the PCP, nurse practitioner, and patient. And it helps prevent unnecessary hospital admissions and expenses.

“We can usually manage a patient’s needs outside of the hospital with coordination and close evaluation,” Binford says. “So, if having a nurse practitioner go see a patient avoids a hospitalization, that cost is a huge financial benefit in the long term.”

Ultimately, a nurse practitioner aims to keep patients as healthy as possible. It’s rewarding to contribute to improved care delivery and patient-provider satisfaction, she says. And working with Honest makes that goal easier to achieve, especially with the implementation of programs like Care at Home that enable this collaborative approach to care.

“The primary care doctors are happy to have patients who are more compliant and out of the hospital,” Baun says. “Patients are happier, more motivated, and feel more in control of their health.”

Learn how Honest and physicians are partnering to deliver elevated care and improve patient outcomes at partnerwithhonest.com.