Transcript Caroline A Knight MD CCFP FCFP Community Family Physician

House Calls 101
Caroline A Knight MD CCFP FCFP
Community Family Physician
Community Preceptor, Department of Family Medicine
University of Ottawa
[email protected]
Conflicts
None
Faculty/Presenter Disclosure
• Faculty: Caroline A Knight MD CCFP FCFP
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
–
–
–
–
Grants/Research Support: None
Speakers Bureau/Honoraria: None
Consulting Fees: None
Other: I am not a hospital employee
Disclosure of Commercial
Support
• This program has received no financial support from any
organization , except anticipated speaker’s honorarium from
OCFP
• This program has received in-kind support from OCFP in the form
of one day’s free registration for this ASA, reimbursement of economy
travel, one night’s hotel accommodation.
• Potential for conflict(s) of interest:
– None
Mitigating Potential Bias
Not applicable
Introductions
Name, what kind of HCP are you?
Where do you practice, type of practice, nonenrolled/FHG/FHO/FHT/Community Health Centre ...
What is your experience of house calls? Have you ever done a
house call? Have you ever received any training in house calls
Why are you here? What do you want to get out of this workshop?
Learning Objectives
What is home-based primary care?
Where?
Why do house calls?
Current practice
Who - which patients to see
When to do house calls
How - some practical tips
How much? Getting paid
Any other questions?
The next step
By the end of the workshop, identify at least one patient in
your practice who would likely benefit from a house call.
Make a commitment to do one or more house calls in the
next 4 weeks.
Exchange email address with a partner to debrief after
doing a house call. Please send me a copy of the emails
too!
What is a house call?
Home based primary care vs. other home care models
N Stall, M Nowaczynski, S Sinha. Back to the future: home
based primary care for older homebound Canadians.
Canadian Family Physician (50) 237-240 March 2013
http://www.cfp.ca/content/59/3/237/T1.expansion.html
5 home-based care models
1. Skilled Home Care
Functional Model: targeted nursing, allied health, social
services
Focus on remediable conditions, supporting independent
living
Time course: time limited or ongoing
Personnel: nursing and allied health professionals
Goals of Care: Support independent living
2. Transitional Home
Care
Functional Model: Medical care after hospital discharge
Care focus: often disease specific e.g. CHF, COPD ...
Time Course: Time limited to a designated period after discharge
Personnel: FP/GPs, nurses, allied health professionals
Goals of care: Prevent adverse outcomes after hospital discharge, improve
coordination and continuity of care, reduce readmissions. Reduce overall
costs of care
3. Hospital-at-Home
Functional Model: Acute medical care in the home
Care focus: Acute illness or exacerbation of chronic disease
Time course: time-limited to the end of an acute episode
Personnel: FP/GP, specialists, nurses, allied health professionals
Goals of Care: Substitute for acute hospital care. Reduce iatrogenic events
(nosocomial infection, functional decline, pressure sores, delirium, falls, etc).
Reduce overall cost of care
4. Outreach Home Visits
Functional Model: Home-based multidimensional geriatric
assessment
Care Focus: Needs assessment
Time Course: Consultation with possible limited follow-up
Personnel: Varied - typically nursing, allied health professionals
Goals of Care: Assess needs and develop care plan to be
implemented by office-based PCP or specialist
5. Home Based Primary
Care
Functional Model: Ongoing, comprehensive primary care in the home
Care focus: Complex and interrelated chronic disease management and social care
issues
Time course: Ongoing
Personnel: Primary care provider-led inter-professional teams
Goals of care: Improve access to primary care. Maximize independence and
function. Reduce ER, hospital and LTC admissions. Enhance patient safety and
quality of life. Link with supportive/skilled home care services
Where?
OHIP Schedule of Benefits:
Home: “patient’s place of residence including a multiple resident
dwelling or single location that shares a common external
building entrance or lobby, such as an apartment block, rest or
retirement home, commercial hotel, motel or boarding house,
university or boarding school residence, hostel, correctional
facility, or group home and other than a hospital or Long-Term
Care institution”
Why do house calls?
The/my pragmatic answers:
How else are patients who can’t/won’t/don’t come to the office going to
receive primary care?
“For patients who are particularly frail or have severe mobility
impairment, coordinating and executing a physician’s office visit often
carries both a financial price and substantial discomfort. ... For patients
with dementia or psychiatric disorders ... leaving home for a clinic visit
may trigger psychological distress, and patients may simply refuse”. (Kao
2009)
Why do house calls?
Rapid psychosocial assessment 0f patient and their living
situation - who’s at home, what is the living situation, is there
food in the fridge, do they have/take meds ... which ones?
Teaching learners
Introduce other care providers
Change of pace from the office
Generate revenue outside the office
Why do Housecalls?
The academic answer ... what does the literature
say?
Do house calls make a difference - is home
based primary care effective?
Why do house calls?
Stall, Nowaczynski, Sinha
5 English-language systematic reviews of home-based care models for the elderly
... conflicting results
“Some ... home visit outreach and PC programs did not affect mortality, physical and
psychosocial function, health status, health care use and costs ... other reviews
concluded ... reduced mortality, admissions to LTC, functional decline”.
Studies are heterogenous, many not aimed at provision of comprehensive ongoing
primary care
UK and Europe - patients maintain office based PCPs, home visits were separate
and independent interventions
Studies do not address access to PC for the homebound and fragmentation of care
Why do house calls?
Stall, Nowaczynski, Sinha
“Learning from the US”
Home-based primary care programs - “the most successful provider
of h0me-based primary care has been the Veterans Health
Administration”
medical house calls by ongoing PCP (MD or NP)
PCP leads an inter-professional care team
program is available after hours for urgent issues.
+/- access to home-based lab and diagnostic imaging services.
Why do house calls?
Stall, Nowaczynski, Sinha
8 studies 2000 - 2012
4 observational (104-468 patients) - inc. one Canadian study
3 retrospective reviews (179 - 20,783 patients)
one multi-site randomized RCT (981/985 patients)
1 - 7 years
Why do house calls?
Stall, Nowaczynski, Sinha
ED visits (4/8) - no difference to 48% decrease
Hospital Admissions (8/8) - 8 - 84% decrease. RCT no difference, but 22% decrease for severely disabled
(p=0.03)
LTC admissions (2/8) - 10- 20% decrease
Why do house calls
May reduce ER use
May reduce hospital admissions (especially in the severely
disabled)
May reduce LTC admissions
Ontario government has promised $60million annually to
support expansion of MD house call services to frail
homebound elderly
House call myths
It’s too time consuming
It doesn’t pay
It’s not safe
“Good medicine” can only be done in clinics and
hospitals
Who needs a housecall?
Anyone who can’t, shouldn’t (or won’t) come to the office
frail elderly with mobility, support or transportation problems
dementia
infection control e.g. immune suppression, VRE positive, 4 children with chickenpox
palliative care
post-natal visits for overwhelmed moms, multiple births
MD should decide to whom to offer house calls based on NEED, not want.
National Physicians
Survey 2007, 2010
National Physicians
Survey - 2007, 2010
National Physicians
Survey 2007, 2010
National Physicians
Survey 2007, 2010
National Physicians Survey
2007 and 2010
National Physicians
Survey 2007, 2010
When to do housecalls - time
management tips
do the occasional house call - before or after the office,
lunchtime
schedule a regular time for house calls - works well in
shared offices, or if the office is closed.
timing - expect to take 30 - 60 minutes (sometimes
longer). Avoid mealtimes for retirement home residents.
How to do a housecall some practical tips
Safety
What to take with you
Charting options
What to do on a house call
Safety
Know as much as you can about the patient ahead of time
Who else is in the home? Pets? Which entrance to use, entry phone ring number.
Carry a cellphone
Don’t go anywhere that you don’t feel safe - go as a team, or (in extreme) ask for
police escort.
Consider chaperone (family member or team member/home care nurse etc)
Let someone know where you’re going - appointment schedule
Safety
Parking
Items in car
Street safety
Safety
In home hazards
Slipping and tripping hazards
Pets
Aggressive family members, neighbours, other occupants of apartment buildings
Smokers
Infection control
Home cooking
Cockroaches and bed bugs
Safety - avoiding hitchhiking bed bugs
http://www.toronto.ca/health/bedbugs/pdf/avoidingbedbughitchhikers.pdf
http://www.ottawainnercityhealth.ca/uploads/files/Documents/Policies/Wo
odGreen_Bed_Bug_Manual_2008.pdf
Safety - avoiding hitchhiking bed bugs
Scrubs or work clothes. Wash clothing in hot water , 20 - 60 minutes in dryer ... or freezer x 2 weeks
Do not remove shoes, wear disposable booties over shoes
Avoid pants with cuffs and open toed shoes
Consider wearing boots and/or tucking pant legs into socks.
Only bring items that are needed to provide care in a sealable plastic container
Avoid setting bag/bin on upholstered furniture, bedding, or carpeted floors, use disposable protective pad, or white
garbage bag under bag
Avoid sitting on or touching furniture, leaning on walls, or handling bedding unless needed
Avoid upholstered chairs; choose a plastic or metal chair and visually inspect before sitting down, or bring collapsible
metal stool
Spray or wipe down any equipment used (and hands and soles of shoes) with alcohol
What to Take With You
Charting
Paper chart is still fastest.
If you use records in portable electronic form,
they should be encrypted (CPSO).
Be aware of security issues with remote access.
What can you do on a
house call?
“The medicine’s the same as in the office”
Examining a patient at home may require a little ingenuity sit on the floor, patient lies on sofa (or bed).
Minor procedures - immunizations, joint injections, ear
syringing (therapeutic peritoneal tap, sutures). Needs preplanning and bring equipment with you.
My approach to a house
call
call ahead to schedule visit (and presence of caregivers)
bathroom and kitchen check (wash hands)
where to visit - living room, kitchen, bedroom
the usual medical visit
check all the lotions, potions, pills and puffers.
tripping hazards and mobility aides
caregivers/family - who are they, caregiver support, what are their questions,
concerns. Elder abuse?
What to do on a house call INHOMESSS
(BK Unwin, PE Tatum Am Fam Physician. 2011;83(8):925-931)
Impairments/immobility
Nutritional status and eating habits
Home environment
Other people
Medications
Examination
Safety
Spiritual health/cultural and ethnic influences
Services
NB This is an encyclopedic approach ... don’t expect to do everything every time!
INHOMESSS
Impairment/immobility
Evidence of cognitive impairment
Demonstration of ADLS (basic, instrumental and advanced)
Balance and gait
Sensory impairment (hearing, vision, taste, smell, tactile)
Falls?
INHOMESSS
Nutritional status and eating habits
check kitchen, foods available
nutritional status
fluid intake
alcohol
swallowing difficulties
oral health
INHOMESS
Home environment
Neighbourhood
Exterior of home
Interior - crowding, good housekeeping, hominess,
privacy, pets, books, TV, memorabilia, telephone,
personal alarm, internet
INHOMESSS
Other people
Caregiver(s)
Caregiver issues - hours per day, stress, coping, abuse, need
for respite, is the caregiver capable?
Social supports
Advanced Directives
Powers of Attorney
INHOMESSS
Medication
Prescription
Non-prescription
Dietary supplements
Medication organization, compliance, discrepancy
Multiple prescribers
Allergies
Written instructions
INHOMESSS
Examination
Weight, Height, BP
Glucose, urinalysis
Montreal Cognitive Assessment
Depression Screen
General physical condition
Focused examination
INHOMESSS
Safety
access to emergency services
adaptations to home
telephone, personal alarm
bathroom, kitchen
carpets, lighting, cords, stairs, furniture
fire and smoke detectors, fire extinguishers
emergency plans, evacuation route
heat, air conditioning
water source (esp. rural), hot water temperature
firearms
Pets
INHOMESSS
Spiritual health, cultural and ethnic influences
Services - Home care, MOW, social services,
transportation, equipment
Other resources to assist with
care at home
CCAC - case management, ongoing support with ADLS e.g.
PSW for bathing, dressing, some meals.
CCAC - episodic focussed care e.g. nursing for IV antibiotics,
wound management, palliative care. OT, PT.
In home phlebotomy and EKG - Gamma Dynacare (?? others).
Cost: $30.00 for home visit - not covered by OHIP
Other resources to assist with
care at home
CHC Primary Care Outreach to Seniors - nursing visits for ongoing monitoring,
patient teaching
Geriatric Community Mental Health - in home mental health support (in Ottawa
mostly psychiatric nurses, social workers, one Psychiatrist)
Geriatric Outreach and Assessment Teams - in- home Geriatric Assessment
Alzheimer’s Society (First Link), Arthritis Society, CNIB, Parkinson’s Society,
Cancer Society, ... various Senior Support organizations - Consult your
Directory of Community Services, CCAC case manager
How much - getting paid
(in Ontario)
OHIP Schedule of Benefits
A901 - House call assessment (first patient seen) - $45.15
A900 - Complex house call Assessment (new - 2013) $45.15
A902 - Pronouncement of Death in the home
PLUS PREMIUMS
How much - Getting paid (in Ontario)
(A900 Complex house call assessment - OHIP SOB A3)
A complex house call assessment is a primary care service rendered in a patient’s home for a patient that is
considered either a frail elderly patient or a housebound patient. The service must satisfy at a minimum, all of
the requirements of an intermediate assessment
Only for the first person seen during a single visit to the same location
Frail elderly patient
65 years or more with one or more of
Complex medical management needs
Poly pharmacy
Cognitive impairment e.g. dementia or delerium
age-related reduced mobility or falls
unexplained functional decline NOS
How much - Getting paid (in Ontario)
(A900 Complex house call assessment - OHIP SOB A3)
Housebound patient:
the person has difficulty accessing office-based primary health care
services because of medical, physical, cognitive or psychosocial
needs/conditions
transportation and other strategies to remedy the access difficulties
have been considered but are not available or not appropriate in the
person’s circumstances
the person’s care and support requirements can be effectively
delivered at home
How much - Getting Paid (in
Ontario) - Special Visit Premiums
max. travel
Travel
Premium
($36.40)
Code
Value
Time
max.
patients
B990
$27.50
Daytime Mon-Fri (07:00 - 17:00)/Elective Home
Visit
10
2
B960
B992
$44.00
Sacrifice Office Hours
10
2
B961
B994
$66.00
Evenings Mon-Fri (17:00-24:00)
10
2
B962
B993
$82.50
Saturday, Sunday, Holiday (07:00 - 24:00)
20
6
B963
B996
$110.00
Night (00:00 - 07:00)
no limit
no limit
B964
How Much - Getting paid in Ontario
Primary care models
Fee for service, Comprehensive Care Model and FHG payment as fee for service
Family Health Network(FHN) - House calls are OUT of
basket
Family Health Organization (FHO) - House calls and
special visit premiums are IN basket, but travel
premiums are OUT of basket
How Much - Getting paid in Ontario
House Call Bonuses and Premiums - FHG,
FHN, FHO
Bonus level
(per year)
A
3 or more patients
served
B
C
D
6 or more patients 17 or more patients 32 or more patients
served
served
served
And
12 or more
encounters
24 or more
encounters
68 or more
encounters
128 or more
encounters
Bonus payment
$1500
$3000
$5000
$8000
PLUS 20% premium on value of claims for house call visits in excess of level C if at
least 75% house calls are A900 (Complex house call)
No bonus or premium for FFS, CCM
Billing Example
•
•
•
•
•
•
•
•
•
•
Pre-arranged house call to 75 year old patient with dementia (and ear wax) on
Monday morning,
A900
Complex house call
45.15
B990
Elective special visit
27.50
B960
Daytime travel
36.40
G420
Ear syringing
11.25
G590
Flu shot
4.50
... and check on spouse’s BP, diabetes, and give another flu shot
K030 Diabetic Management Assessment 39.20
G590
Flu shot
4.50
TOTAL for 1 house call (2 patients)
$168.50
The next step ...
Think of one patient in your practice who would benefit from a
home visit
In a pairs or groups of 3, describe that patient, why you think they
would benefit from a home visit
In the next 2-3 weeks, do a house call.
Report back to your partner or group (email ... no patient names
though). Please cc me too - [email protected].
Reflection on the house call
experience
What did you learn about the patient that you didn’t already
know?
What changes did you make to your management?
How did the patient and family react to you making a house call?
What went well?
What would you do differently next time?
Questions?
Photo courtesy of Dr Alice Gwyn, Nfld
References
N Stall, M Nowaczynski, S Sinha. Back to the future: home based
primary care for older homebound Canadians. Canadian Family
Physician (50) 237-240 March 2013
http://www.cfp.ca/content/59/3/237/T1.expansion.html
The Past, Present and Future of Housecalls. Kao et al. Clin Geriatr
Med 25(2009)19 -34
BK Unwin, PE Tatum, Am Fam Physician/ 2-11;83(8):925-31.
Excellent summary with checklist (INHOMESSS mnemonic), list of
equipment
References
House Call Safety
http://osach.ca/products/resrcdoc/lap_301.pdf
http://giic.rgps.on.ca/files/Be%20Safe%20Guide%20to%20Home%20
Visits%20from%20Providence%20Healthcare.pdf
Bed Bugs
References
Getting Paid
OHIP Schedule of Benefits October 1 2013
OHIP Infobulletin #11064 February 25, 2013
SFGP Common Family Practice Codes - January 1 2013
OMA Primary Care Comparison - March 2013
https://www.oma.org/Member/Resources/Documents/PCRCo
mparisonChart.pdf
National Physicians
Survey 2007, 2010