Transcript Home Care: The past, present, and future offerings

The Evolution of
the SLVCS
Hospital at Home
Program
Lumie Kawasaki, M.D., M.B.A.
March 24, 2011
Objectives
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To provide an understanding of the general Hospital at
Home model in the context of other home care
models.
To describe the formation and development of the
SLVHCS Hospital at Home program
To provide a current snapshot of the SLVHCS H@H
program.
To identify benefits, limitations, lessons learned; and
To describe the next phase in development
Hospital at Home Model
Arose from a need for alternative models to
reduce reliance on inpatient care due to:
• excess demand over supply of acute
hospital beds,
• growing health care technology,
• greater emphasis on cost-containment
measures
• inpatient care may not always produce
optimal clinical outcomes for some
groups of patients – particularly the
elderly.
Background
Hospital at Home is an alternative model to
inpatient care
• International model
• Types: “early-discharge” “substitution”
• Meta-analysis
• improved patient satisfaction
• clinical outcomes with traditional
hospitalization
• Johns Hopkins/Bruce Leff, MD
• Portland VAMC/Scott Mader, MD
• Hawaii VAMC
Background
The post-Katrina environment had:
– Reduced hospital bed capacity and crowded ERs due to
multiple hospital closures, including the SLVHCS-based
Inpatient Services.
– Greater reliance on local non-VA hospitals (33), and
other VA hospitals within VISN 16, leading to
fragmented care, redundant diagnostic studies.
– Highlighted the vulnerabilities of older adults with
higher mortality and depression post-Katrina.
– Exponential growth in the SLVHCS veteran population
(151%) as veterans returned “home
SLVHCS Hospital at Home opened October 1, 2007 to help
address some of these needs…
The Concept of Home
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Physical Structure
Territory
Locus in space
Self and self-identity
Social and cultural unit
Familiar
Center
Protector
Healer
“The image of a physician delivering care to a sick
patient at home is one of the essential and
enduring images in the collective consciousness of
medicine. It is an image that no doubt once
inspired, and perhaps still inspires, some to pursue
a career in medicine. It is an image from which
the medical profession, as a whole, once drew
inspiration so as to say “Yes, this is what
physicians are about. Physicians take care of
patients.”
Leff, B. “The Future History of Home Care and Physician House
Calls in the United States,” 2001
Uniqueness of Home Visits
Improved balance of power
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Qualitative interview study performed, as part of a large randomized
psychosocial intervention study on the effects of home visit to Danish
patients with colorectal cancer. N=21 informants.
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“Healthcare interventions in patients’ homes result in a well-balanced contact
between the professional visitor and the patient by overcoming the barrier felt
by patients in the hospital setting, where they are sometimes treated as
objects. Meeting patients in their home setting gave the visitor a deeper
understanding of them as persons and facilitated dialogue about their daily
lives, problems, social network, and social resources.”
Ross, L, et al. Cancer Nursing. 2002
Uniqueness of Home Visits
Understanding the client’s health need as he or
she sees it
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N=200
Prospective, repeated-measures design study, focusing on patient safety
and caregiver issues.
Compared the yield of a clinic-based home assessment with the yield of
a home visit involving patients with dementia.
84% of serious problems were identified only at home visit, not at clinic
visit. Issues: social isolation, caregiver stress, fall risk.
Ra,sde;;. KW. et al, Alzheimer Dis Assoc Disord, 2004
It is difficult to express in words the difference between
knowing patients by their visits to the office and knowing
them as a visitor to their homes. The home is where a
family’s values are expressed. It is in the home that
people can be themselves. The history of the family – its
story, its joys and sorrows, its memories and aspirations
are this reason assessment in the home is different from
assessment in the office or the hospital. Instead of
asking about activities of daily living, we see patients in
their own bedroom, bathroom, and kitchen, climbing
their own stairs, and so on. When we review the
medications, we can assemble them all-including those
from the bathroom cabinet—by the bedside or on the
kitchen table. We can sense for ourselves either the
peace or the tension in the home. We can meet with the
family on their own ground, where they are most likely
to express their feelings. In the home the patient can be
in control of his or her own care, and this can be a
powerful influence on healing.
McWhinney, Ian R.
Uniqueness of Home Care
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Equal balance of power
 Understanding of patient’s health needs as he or she
sees it
 Community connections
 Social model -– Improved understanding of physiological/psychological
aspects of one’s disease
– Improved coping
– Enhanced social supports and contacts
– Improved knowledge of community resources
– Broader understanding of patient on part of the health
professional
Home Care Models
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Preventive
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Transitions of care
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Primary Care/Longterm
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Acute Care Model
Preventive Care
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Meta-analysis, 15 studies
– 9 studies to general elderly population
– 6 studies to older adults at risk for adverse events
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Significant impact on mortality, admissions to long-term care institutions.
Elkan R, et al. BMJ 2001
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3-year RCT, N=215, 75+yo, Geriatric APN in collaboration with
geriatrician. Annual CGA with quarterly follow-up.
Significant impact on disability (ADLs) and permanent nursing home stays.
Stuck A et al. NEJM 1994
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3-year stratified randomized trial, 75+yo, RN in collaboration with
geriatrician. Annual CGA with quarterly follow-up.
Reduce risk for elderly at low risk, but not at high risk for functional
impairment.
Stuck A et al. Arch Int Med 2000
Transitional Care
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Care Transition Coaching
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APN “transition coach,” begin in hospital and 30-day post-discharge
Encourages family caregivers to assume more active roles during care transitions, focusing on med
mgmt, follow-up with physician, red flag list. Personal health record maintained by pt/caregiver.
Lower all-cause re-hospitalization rate at 30 and 90 days reduced. Lower costs . (Coleman et al, Arch Int
Med, 2006)
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APN transitional care model
– APN-directed, begin in hospital, arranges post-discharge plans. 7-day per week
telephone access.
– 3 RCTs: greater pt satisfaction, lower readmissions, decreased costs.
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CHF/Disease Management
– Post-discharge visit by RN, pharmacist, or cardiac nurse within 7-14 days for structured,
comprehensive visit, including barriers to treatment adherence (e.g. social support). 3-6
years.
– Reduced all-cause mortality, longer survival, longer event-free survival, fewer unplanned
readmissions, shorter hospital stay if admitted, fewer ICU admissions. (Ahern MM et al,
Disease Management, 2007; Simon S et al, Circulation, 2002)
Primary/Long-Term Care
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VA- Home-Based Primary Care
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Physician Home Visiting Program
VA Home-Based Primary Care
Differences Between VA HBPC and Medicare Home Care
VA HBPC
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 and intesnity
Anywhere; anytime
Clinician Rankings of Factors Influencing
House Calls
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N=36
 10-point scale reflecting weight of influence
 Motivators:
– Improved patient care
– Autonomy
– Positive experience with house call
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Barriers:
– Lack of training regarding house calls
– Inconvenient
– Inadequate compensation
Landers SH et al, Case Management Journals 10 (3), 2009
Clinician Rankings of Factors Influencing
House Calls
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N=36
 Open-ended questions/answers
 Most frequently cited reasons:
– Desire to care for underserved population
– Desire for better patient relationships
– Financial and lifestyle issues
Landers SH et al, Case Management Journals 10 (3), 2009
“It gives you a much better picture of what is going
on with the patient and their family than you can get
in the office.”
“It gives you a more intimate relationship with
patient and family and they trust you more.”
“Better able to use family to improve life-health of
index patient.”
“I saw a glaring deficit in adequate care for elderly
patients.”
Landers SH et al, Case Management Journals 10 (3), 2009
Conceptual Role of Home Care for Older Adults
Home Care Resources
Preventative
Acute
Transitions of Care
Function
LTC
Time
Acute Care
SLVHCS Hospital at Home Focus of Service
The SLVHCS Hospital at Home program provided key hospital services within
the home setting for those conditions that could safely be provided in the
home. It initially was structured as an “early-discharge” model (i.e. veterans
were discharged “early” from their traditional hospital stay to Hospital at
Home) .
This focus has since expanded, evolving to address the identified needs of
SVLHCS veterans by providing:
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Early discharge of veterans from the hospital;
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Substitution of the traditional hospitalization (i.e. admission occurs from
the UCC, ER or clinics without veterans staying in the traditional hospital);
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Modified long-term acute care service (“LTAC”) for patients in need of
longer-term services (e.g. IV medications, for osteomyelitis intensive
wound care)
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Preventative approach to minimize hospitalizations and/or ER evaluations
for high-risk patients (e.g. patients with high systemic utilization in the
ER/UCC and/or with frequent hospitalizations)
SLVHCS Hospital at Home
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Operational Components
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Initial MD evaluation with daily treatment plan oversight
Daily skilled RN home evaluation
24-hour, 7 day a week telephone access to RN and MD
Low RN/patient
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Hours: 7:30 AM – 2 pm (same-day admission). Most admissions occur the next day
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Medical Services:
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IV medications
In-home lab draws and delivery (same day available)
Respiratory services
HBPC disciplines (Dietician, Rehab, Pharmacy, SW, MH)
Target veterans:
 SLVHCS veterans -- not limited by age – residing within 25 miles of the NOLA and
Slidell clinic sites in need of (1) acute/sub-acute services which can be delivered safely
in the home; (2) who are at risk for hospitalizations
SLVHCS Hospital at Home
Organizational Structure
 H@H falls within the HBPC umbrella, providing acute/sub-acute services
within the established chronic disease model of HBPC.
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Dedicated H@H FTE: RNs (including 1 Program Coordinator)
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Complete staff overlap within “chronic” HBPC and H@H, which facilitates
seamless transitions of care. The following services are provided within
the home setting:
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Physician
Dietician
SW
MH
Pharmacy
Rehab
Cross-training of all HBPC RNs to H@H care, allowing flexible crosscoverage, as needed, to promote optimal resource utilization.
SLVHCS Hospital at Home
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age: 69 (38-94)
 Since inception: 178 unique veterans
served with 223 admissions (18%
readmission rate)
 FY10-FY11 : 146 uniques
 Average # chronic conditions: 8
Most Common Admitting
Diagnoses
CHF
COPD
Cellulitis
UTI/urosepsis
DVT/PE
Post-op wound care
Pneumonia
At risk Hyperglycemia
At risk HTN
The Partnerships…
The SLVHCS Hospital at Home program
works directly with all SLVHCS services.
The general distribution of referrals are as
follows:
 Tulane Inpatient Service
 Chronic disease HBPC
 VA Urgent Care
 Clinics
 Community
51%
25%
14%
7%
3%
SLVHCS Hospital at Home
Length of Stay
Substitutive
Early Discharge
LTAC
Preventative
6 days
7 days
16 days
7 days
SLVHCS H@H Incremental Cost Analysis
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Assumption: annual H@H admission = 100
Revenues (VERA reimbursement, $22k, 38% eligibility)
$638k
Start-up equip/suppl costs (excluding space) $ 15,000
Annual Expenses:
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Personnel (2 RNs, 0.5 MD)
IV infusion
Lab draws (Tulane)
Cars ($340/month, 3 cars)
$375,000
$ 23,100
$ 14,000
$ 12,240
Total Expenses (start-up, annual)
$439k
Additional cost savings may occur from hospital avoidance via the
substitutive model:
$320k
Benefits
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Veterans are given a greater choice in how and where they receive
their care;
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Improved transitions of care
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Broader continuum of services within HBPC, creating a potentially
new paradigm in the model of home care.
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Encourages collaboration of services and partnerships with
patients/caregivers.
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Less fragmentation of health care delivery.
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Potential cost savings
Conceptual Role of Home Care for Older Adults
Home Care Resources
Preventative
Acute
Transitions of Care
Function
LTC
Time
Limitations
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25-mile/30 minute driving limitation
Any further geographic expansion will lead
to greater travel time and less efficiency of
care delivery.
Comparative geographic distribution of
SLVHCS veterans suggest greater
rural/suburban growth?
Tele- Hospital at Home
A remote monitoring component of Hospital at Home, utilizing real-time telemonitoring equipment .
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Potential Benefits:
– Improved access to care with the potential to expand to a broader geographic region;
– Greater efficiency of staffing (visits q2-4 days)
– Real-time monitoring with capacity to conduct respiratory, cardiac, wound, and
abdominal assessments.
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Insights gained:
– Quality of the equipment provides a strong adjunctive service.
– Potential areas of service appear to match major focus of H@H.
– There is need for caregiver present to assist with placement of peripheral devices on
the machines (e.g. placemen of the stethoscope to the back).
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Hurdles
– Reliance on caregiver
– Equipment transport
– Patient acceptance?
Lessons Learned
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The success of the SLVHCS Hospital at Home
program has occurred through strong leadership
support.
As a new innovative program, there is a need to
market again and again and again…to each
service.
Need for dedicated staff who believe in what this
model of care can provide
Contact Information
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For questions about this audio conference please contact
Dr. Lumie Kawasaki at [email protected]
For any questions about the monthly GRECC Audio
Conference Series please contact Tim Foley at
[email protected] or call (734) 222-4328
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