Geriatrics COVE team makes house calls for older people – and reduces hospital readmissions

Ongoing health care can reduce the risk of hospital readmission. But patients with these challenges are usually older and dealing with mobility or access barriers. They struggle to get to regular checkups for chronic conditions such as high blood pressure or diabetes, which makes them less likely to stick to a treatment plan and more likely to need costly advanced or emergency care.

To face this challenge head on, UT Southwestern launched our home-based primary care, Care of the Vulnerable Elderly (COVE), in 2015 – and it’s working.

COVE is unique in North Texas, providing home-based primary care, chronic care management, transitional care, and support to alleviate social determinants of health (SDOH). Backed by a team of primary care and geriatrics experts, we help patients manage their health, which in turn reduces hospital readmissions and challenging, time-intensive trips to the hospital.

Research suggests that house call programs like COVE could lower hospital readmissions by 21%, reduce nursing home use by nearly 90%, and save $2,000 in Medicare costs per patient each year. In nine years, COVE has grown from 70 patients to 450, and we are expecting to expand along with the aging population – people 65 and older are the fastest-growing age group in Texas.

Team-based services at home

Successful home-based primary care programs are led by both physicians and nurse practitioners (NPs) who are experienced in managing older patients with multiple chronic conditions. COVE is staffed by advanced practice NPs, geriatricians, clinical social workers, a clinical coordinator, and registered nurses with geriatric expertise.

Together, we provide a range of services that allow patients to get the care they need without having to leave home.

Full-service primary care

Advances in mobile equipment such as mobile imaging have made it possible to evaluate and help manage many health conditions at home. COVE providers can offer nearly any type of care performed in a health care clinic, including:

• Blood draws
• Cortisone joint injections
• Nutrition
• Imaging such as X-rays, ultrasound and EKG
• Cognitive behavioral therapy
• Medication management
• Comprehensive Geriatric Assessment, including the Medicare Annual Wellness Exam
• Preventive screenings
• Vaccinations, including the flu shot, pneumonia vaccine, and COVID-19 boosters

While patients will have to visit a UTSW center for some advanced exams and procedures, the COVE team can help families and specialists streamline appointments to reduce trips to the clinic. Our program can reduce specialty visits by almost 60% by providing collaboration and care coordination with the specialists.

Chronic care management

We also offer a chronic care management program for patients with one or more chronic conditions. Patients enroll by choice in this program, and the doctor or NP creates a care plan for them. The nurse then follows through to guide them in following the care plan. CCM has been shown to improve patient satisfaction.

Patients and family caregivers have told us they feel better knowing that we have a proactive approach rather than trying to arrange follow-up care on their own.

Chronic conditions we help manage individually or in combination can include:

• High blood pressure
• Diabetes
• Strokes
• Chronic obstructive pulmonary disease
• Dementia – about 40% of COVE patients have a dementia diagnosis
• Heart failure

By caring for all the patient's needs in one visit, COVE also helps families avoid charges for frequent clinic visits to address individual conditions.

COVE is expanding to offer caregiver support, particularly for those caring for someone with dementia. This could take the form of check-ins during appointments as well as virtual and in-person support groups. Caregivers are our partners, and they often need guidance to balance self-care with navigating their loved ones’ conditions and treatments.