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Home Based Chronic Care Steven L. Phillips, MD, CMD 2005 AGS Annual Meeting Orlando, Florida stevenl

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stevenlp_at_charter.net. Chronic Diseases in the Elderly. Diabetes Mellitus 15-25 ... Washington, DC: Institute of Medicine, Committee on Care at the End of Life, ... – PowerPoint PPT presentation

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Title: Home Based Chronic Care Steven L. Phillips, MD, CMD 2005 AGS Annual Meeting Orlando, Florida stevenl


1
Home Based Chronic Care Steven L. Phillips, MD,
CMD 2005 AGS Annual Meeting Orlando,
Florida stevenlp_at_charter.net
2
Chronic Diseases in the Elderly
  • Diabetes Mellitus 15-25
  • Hypertension 10-15
  • Coronary Artery Disease 10-14
  • Arthritis/DJD 10-13
  • Emphysema 5-7
  • Dementia 5-7
  • Depression/Anxiety 3-5
  • Cerebrovascular Disorders 3-5

3
A Century of Change
4
Americans Current Health Care Expenditures
5
Change in the New Century
6
(No Transcript)
7
Trajectories of Chronic Illness Service Needs
Across Time
8
Short Period of Evident Decline Mostly Cancer
9
Long-Term Limitations with Intermittent Serious
Episodes Mostly Heart Failure and Lung Failure
10
Prolonged Dwindling Mostly Dementia, Disabling
Strokes, Frailty
11
Frailty
  • Fragility of multiple body systems as their
    customary reserves diminish with age and disease
  • A fatal chronic condition in which all of the
    body systems have little reserve and small upsets
    cause cascading health problems

12
Analysis of Medicare Claims
  • Short Period of Evident Decline 20
  • Long-Term Limitations with Exacerbation 20
  • Prolonged Dwindling 40
  • Sudden Death and Not Yet
    Classified 20

13
Current Health Care System
  • Shaped largely in the two decades after World War
    II
  • Designed mainly to prevent illness and to
    engineer rescues from injury or illness
  • Works well for younger, basically healthy people
  • Success has contributed to the dramatic
    improvements in American life expectancy

14
Current System Organized by Setting
  • Hospital
  • Nursing Facility
  • Home
  • Doctors Office

15
Impedes continuity of care across settings and
across the changing challenges of worsening
illness
16
Clinical Care Model
  • Physicians
  • Advanced Practitioners of Nursing
  • Physician Assistants
  • Licensed Clinical Social Worker
  • Nurse Case Manager
  • Clinical Pharmacist
  • Therapists

17
Clinical Care Model Flowchart
Care Where They Reside Office, Hospital, SNF, AL
F, Home
Office, Hospital, SNF, Home Health
Anytown Geriatric Associates
Combined Evaluation
DRG, MDS, RUG, OASIS, HHRG
Additional Recommendations
Social Services
Infusion
DME
Home Health Visits
Provider Home Visit
Palliative Care
Private Duty Nursing
Outcomes
Death
Continued Care
Hospice Care
Return to Ambulatory Care
18
Spreading the Risk
  • Go Where They Reside
  • Maximize Other Resources
  • Minimize True Exposure

19
SENIOR DIMENSIONS CHRONIC HOME CARE
  • Program Intent
  • Definition of Client
  • Guidelines for Assessment
  • Recertification of Services
  • Effectiveness of Program
  • Potential for Replication

20
Program Intent
  • Augment Care of the Chronically Ill beyond
    Skilled Care Needs
  • Shift from a Medically Driven Model of Care
  • Psychological
  • Functional
  • Social
  • Bring the Program to Where the Client Resides

21
Definition of Client
  • All SHMO Members
  • with 3 or more hospitalizations
  • in the past 6 months
  • related to 1 or more chronic illnesses

22
Definition of Client
  • SHMO Member with
  • monthly foley catheter change and unable to be
    done in provider office
  • skilled wound cared completed and skin healed
    ongoing nursing involvement
  • required to prevent further skin breakdown
  • chronic wound care client or family unable to
    get to wound care center or provider office

23
Definition of Client
  • Frail Elderly/Disabled
  • requiring regular physical assessment more
    frequently than an interval of 60 days or more
  • inadequate support system
  • malnourished
  • multiple ADL/IADL deficiencies

24
Guidelines for Assessment
  • Chronic Disease Knowledge
  • Medication Setup, Knowledge, and Adherence
  • Physical Symptoms and Signs
  • Adequate Food and the Ability to Prepare and Eat

25
Guidelines for Assessment
  • Social Support
  • Environmental Safety
  • Functional Ability
  • Available Community Resources

26
Recertification of Services
  • Are chronic home health visits needed?
  • Does the client need to be transitioned to acute
    home care level?
  • Can the client be transitioned to ambulatory care
    management?
  • Can the client be transitioned to hospice?

27
Effectiveness of Program
  • Audit Reviewed Utilization of
  • Acute Hospital Days
  • Subacute Days
  • Skilled Days

28
Effectiveness of Program
  • N 300 patients
  • 6 months prior to program
  • Days /Day Total

  • Hospital 1157 1200 1,388,571.00
  • Subacute 1691 425 718,764.00
  • Skilled 70 225 15,577.00
  • Total 2,122,912.00

29
Effectiveness of Program
  • N 300 Patients
  • 6 months after admission to program
  • Days /Day Total
  • Hospital 438 1200 526,154.00
  • Subacute 300 425 127,500.00
  • Skilled 197 225 44,505.00
  • Total
    698,159.00

30
Effectiveness of Program
  • Bed Day Savings
  • for Population 1,424,753.00
  • Cost of Chronic Home
  • Care Team 741,758.00
  • Total Savings 682,995.00

31
Potential for Replication
  • Adequate Financing
  • Provider Education
  • Client and Family Acceptance

32
Poster Abstract D 108 AGS-2005 T. Edes, S.
Kendall Geriatrics and Extended Care, Dept. of
Veterans Affairs, Washington, DC
  • Longitudinal Home Care for Chronic Disease
  • Retrospective Longitudinal Case-Controlled
    Analysis of Total Health Care Costs
  • 75 Home-Based Primary Care (HBPC) Programs in the
    Department of Veterans Affairs-2002
  • At Least 6 Months if VA Care Prior to Entering
    HBPC Program

33
Criteria for Home-Based Primary Care Program
  • Clinician Referral for HBPC
  • Complex Chronic Disease
  • Need for Interdisciplinary Care
  • Not Effectively Managed in Clinic
  • Risk for Nursing Home Placement

34
Criteria for Home-Based Chronic Care Program
  • Risk for Recurrent Hospitalization
  • Arduous to Leave Home Without Assistance of
    Device or Another Person
  • Neither Skilled nor Strict Homebound Status
    Required

35
Total Health Care Costs Compared 6 Months Prior
to and After Enrollment in HBPC
  • Hospitalization
  • Emergency Care
  • Nursing Home
  • Outpatient Care
  • Ancillary-Lab and Radiology
  • Medication/Supplies
  • Home-Based Primary Care

36
Home-Based Primary Care Team
  • Nursing
  • Social worker
  • Rehab Therapists---PT/OT
  • Dietitian
  • Physician---Oversight and Visits PRN
  • Administrative and Pharmacy Support

37
Results
  • 11,335 Veterans Qualified
  • 28 Lived Alone
  • 47 Dependent in 2 or More ADLs
  • Mean Duration of HBPC 177 Days
  • Average Monthly Visits 3.6

38
Prevalence of Diagnosis
  • Heart Disease 72
  • Diabetes 53
  • Heart Failure 26
  • Chronic Lung Disease 23
  • Stroke Deficit 15

39
Total Cost of Care Per Patient Per Year (Prorated)
  • Prior to HBPC 38,166.00
  • During HBPC 28,690.00
  • p value
  • Including Added Cost of HBPC of
  • 8,706.00 per Patient per Year

40
Integrated Goals
Personal Family Retirement Activities
Professional Clinical Academic Administrative


Organizational Type of practice Position in pr
actice
Other service areas
Financial Salary commensurate with training,
time
invested, experience, and responsibility
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