VA HomeBased Primary Care Pushing the Boundaries

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VA Home-Based Primary CarePushing the
Boundaries

• Thomas Edes, MD
• Director of Home Community-Based Care
• Geriatrics Extended Care
• Office of Patient Care Services

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Home-Based Primary Care

• What is Home-Based Primary Care (HBPC)?
• Can we afford HBPC? Can we afford not to?
• Pioneering quality measures for chronic disease
• Medical Foster Home A new place to call home

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VA Home-Based Primary Care What is HBPC ?

• Comprehensive, longitudinal primary care
• Interdisciplinary team Nurse, Social Worker,
  Physician, Therapist, Dietitian
• Delivered in the home
• Complex, chronic, progressive disease
• For whom routine clinic-based care is not
  effective

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HBPC is NOT like Medicare (MC) Home Care

• Different target population
• Different process
• Different outcomes
• HBPC provides longitudinal, comprehensive,
  interdisciplinary care to veterans with complex
  chronic disease

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Differences Between VA HBPC Medicare Home
Care VA Home Based Primary Care Medicare Home
Care Targets complex chronic disease Remediable
conditions Comprehensive Primary Care Specific
problem-focused Skilled care not
required Requires skilled care Strict
homebound not required Must be
homebound Accepts declining status Requires
improvement Interdisciplinary team One or
Multidisciplinary Longitudinal
care Episodic, post-acute care Reduces
hospital days No definitive impact Limited
geography intensity Anywhere anytime
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Disease Prevalence in HBPC Population

• Percent of patients Disease with
  disease
• Heart disease 72
• Diabetes 53
• Heart failure 26
• Cancer 25
• Chronic lung disease 23
• Dementia 17
• Stroke deficit 15

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Total Health Care CostBefore vs During HBPC
Columbia MO VAMC, 1994
VERA Allocation
Health Care Cost Per Patient Per Year
Total Annual health Care Cost per patient (n30),
contrasted with the VERA allocation of
approximately 33,000/patient/year for t heir
care. The cost of health care for the 6 months
prior to enrollment in Home-Based Primary Care
(HBPC) is compared with the cost of care while
in HBPC. The cost of HBPC is included. T Edes.
JAMA 1999 282 1129
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2002 Utilization Before vs During HBPC All HBPC
programs n11,334Care days or visits per
patient per year
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Costs of Care Before vs During HBPC (per patient
per year)
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Different Outcomes

• Analysis of 1 mil MC home care patients, 3 mil
  home visits
• - no impact of MC home care on hospital days
• - no impact of MC home care on total cost of
  care
• Retrospective case-control national analysis
• - all VA HBPC patients FY02 (11,334 veterans),
  avg 177d
• - 63 reduction in hospital days
• - 87 reduction in nursing home days
• - Cost of longitudinal HBPC 8,706 per patient
  per year
• - Net 24 reduction in VA total cost of care
• HC Welch, NEJM 1996
• T Edes, JAGS 2005

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Increase in Home-Based Primary Care
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Why We Need Quality Measures Specific for Chronic
Disease

• Panel size cant keep up
• Preventive measures many not appropriate, so
  seek exceptions or score poorly
• Polypharmacy many outliers among complex
  patient population
• Monitor improvement - score negatively if the
  condition does not improve.
• Disease management not applicable for multiple
  co-morbidities
• We do not measure what we do not do

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Measures for Longitudinal Care of Complex Chronic
Disease

• Family and caregiver satisfaction support
• Hospitalization
• Not rate of use, but rate of change
• Not population mean, but individual trajectory
• Medication management/adverse events
• Coordination Beyond disease management
• Indicator of quality of care, not characteristics
  of patient population

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Gaps in care

• Emergency? Ambulance on its way
• Acute care? Hospital with open doors
• Post-acute? Skilled needs in home
• Cant manage at home? Nursing home
• Actively dying? Hospice is with you

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Gaps in care VA Answers

• Complex chronic disease?
• Worsens gradually, relentlessly?
• Disabling arthritis, dementia, heart failure
• Where do you turn?
• Home care? No skilled need not homebound
• HBPC? Great until can no longer live alone
• Hospice? Prognosis of several years alone
• Nursing home? Please, not yet . . .
• We need helpFinding our way home

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Medical Foster Home

• Partnership of Foster Care with HBPC
• Alternative to nursing home placement for
• - dependent, chronically ill, or terminally
  ill veterans
• - unable to live independently, and
• - prefer a family setting for their long-term
  care.
• Average age 72yrs Number of major
  problems 8
• Prominent Dx Dementia, CVA, Heart Disease,
  COPD
• All eligible for nursing home care
• Foster care costs paid by veteran sources SS,
  VA

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Next Steps for Progress

• Expand access to HBPC
• Higher satisfaction GAO compliance
• Lower cost of care reduce divert costs
• Develop quality measures that encourage rather
  than punish for taking on chronic disease.
  Suggestions?
• Expand Medical Foster Home view video
• Contact thomas.edes_at_va.gov