Title: Home Care in The VA System Pushing the Boundaries with Home Based Primary Care
1Home Care in The VA System Pushing the
Boundarieswith Home Based Primary Care
- Thomas Edes, MD
- Director of Home Community-Based Care
- U.S. Department of Veterans Affairs
- May 3, 2007
2Objectives
- A. Demographic imperative and complex chronic
disease - B. What is VA Home Based Primary Care ?
- D. Different and complementary
- E. Gaps in care - home care is the solution
- E. Measuring success
3 Change in Population from 2000
85
65
Total
4US Population by Age, in Millions Increase from
2000
5Demographic Imperative Projections from 2000 to
2010
- US pop age 85 to increase 44
- Vet pop age 85 to nearly triple, up 190
- Of all Americans over age 65, one-fourth are
veterans - We are ALL taking care of veterans
- VA facing challenges a decade earlier
6Increasing Disability with Age
- Percentage with dependency in at least 1 Activity
of Daily Living (ADL) bathing, dressing,
toileting, transfer and feeding - Age 65 10
- Age 75 18
- Age 85 47
7Gaps 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
8Gaps in care Whats the answer?
- Complex chronic disease?
- Worsens gradually, relentlessly?
- Disabling arthritis, dementia, heart failure
- Where do you turn?
- Home care? No skilled need not homebound
- Hospice? Prognosis of several years alone
- Nursing home? Please, not yet . . .
- We need helpFinding our way home
9VA Home-Based Primary Care What is HBPC ?
- Comprehensive, longitudinal primary care
- Interdisciplinary team Nurse, Social Worker,
Physician, Therapist, Dietitian, Pharmacist - Delivered in the home
- Complex, chronic, disabling disease
- When routine clinic-based care is not effective
10HBPC 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
11Differences 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
12Characteristics of HBPC Population
- Mean age 76.5 years 96 male
- 47 dependent in 2 or more Activities of Daily
Living (ADL) - 47 married 29 live alone
- Caregivers 32 have limitation in ADL
- Mean duration in HBPC 454 days 3.1 visits/mo
- Medicare home care 65 days Home Hospice 61
(2004)
13Disease Prevalence in HBPC
- Percent of patients Disease with
disease - Heart disease 72
- Diabetes 48
- Heart failure 35
- Dementia 33
- Cancer 29
- Chronic lung disease 16
- Stroke deficit 15
14Total 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
152002 Utilization Before vs During HBPC All HBPC
programs n11,334Care days or visits per
patient per year
16Costs of Care Before vs During HBPC (per patient
per year)
17Different 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
18HBPC Reduction in Hospital Utilization
- Quality Measure implemented Sept 2006
- Measure Percent reduction in number of inpatient
admissions and number of inpatient days - Compare VA hospital and nursing home utilization
DURING HBPC, to 6 months BEFORE enrollment in
HBPC
19Primary Findings
- 12 months to 3/31/06 n 10,050
- Inpatient admissions Mean 26.8 reduction
- Decrease from 3.9 to 2.8 admits/1000 pt days
- Range 207 increase to 67 reduction
- Inpatient Days Mean 69.0 reduction
- Decrease from 64.0 to 19.6 inpt days/1000 pt days
- Range 67 increase to 89 reduction
- 49 drop in hospital, 83 nursing home
20Analysis of VA Facilities
21(No Transcript)
22View of VISN by Station
23Drill Down to Patient Level
Drill Down
24Individual Patient Information Available
- SSN
- Gender
- Age
- PCP
- HBPC Enrollment/ Discharge Dates
- Total of Days Enrolled in HBPC
- of Inpatient Admissions Before and During HBPC
- of Inpatient Days Before and During HBPC
- ED Visits During Reporting Period
- Direct and Total VA Costs
25Sort by Number of ED Visits
26Factors likely to reduce avoidable hospital days
- Target high risk of future hospitalization high
prior inpatient days - Care that is comprehensive interdisciplinary
- Care that is longitudinal and coordinated
- Vigilant responsive
- Medication management
- Communication across settings, providers,
transitions
27Conclusions
- Home care impact on inpatient days is feasible as
quality measure - VA HBPC associated with reduction in hospital and
nursing home days - Home care that is longitudinal, comprehensive and
interdisciplinary may have clinical and economic
advantages vs clinic based care
28Conclusions
- 4. Quality measure that encourages enrollment of
complex chronic disease - 5. Effective management by comprehensive
longitudinal home care - 6. Measuring impact on inpatient days may
identify models of varying success in management
of persons with complex chronic disease