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Home-based primary care: a VA innovation coming soon.

THE U.S. DEPARTMENT OF VETERANS AFFAIRS' (VA) Home Based Primary Care (HBPC) program provides comprehensive longitudinal primary care delivered in a veteran's home by an interdisciplinary team comprising nurses, physicians, social workers, rehabilitation therapists, dieticians, pharmacists and psychologists. (1)

These professionals develop an individualized patient-centered unified care plan as a team, work as a team in caring for the veteran, and meet regularly as a team to review progress and refine plans. The program targets veterans with complex, chronic and disabling diseases for whom routine outpatient clinic care is ineffective. The program manages them through advanced stages of their diseases. (2)

Clinic care may be ineffective for many reasons; patients may have trouble remembering multiple appointments, and traveling to them may be difficult. Also, they may be in pain and unable to wait for long periods in the clinic, be unable to drive safely in the dark, or simply have too many medical problems to be effectively dealt with in a typical clinic visit. In other words, these patients are often "too sick to go to a clinic."

As a result, these patients often miss appointments, their care is poorly coordinated, and they tend to have frequent emergency room visits and preventable hospital and nursing home admissions. HBPC provides comprehensive care in the home, with the bonus of being able to assess the safety and quality of the home environment.

The overall goal of HBPC is to maximize the independence of the patient while reducing preventable emergency room visits and inpatient admissions. HBPC also can:

* Assist with transitions from a health care facility to the home.

* Support and train a family caregiver in the care of the veteran.

* Help the veteran and the family cope with all elements of chronic disease.

* Adapt treatments to changing needs and preferences of the veteran over time.

* Allow the veteran the option of receiving hospice and palliative care at home at the end of life rather than in an institution.

Currently about one-fourth of veterans enrolled in HBPC also are receiving hospice and palliative care services.

The mean age of VA HBPC enrollees is 76.5 years, 96 percent are men, nearly half are dependent in two or more activities of daily living, and the typical patient has eight chronic conditions and takes 12 medications. (3)

Table I shows disease prevalence among veterans enrolled in HBPC. Mental health conditions are notably prevalent, which prompted VA to establish mental health providers as part of every HBPC team beginning in 2007.

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Nearly half of HBPC patients are married; one third of the spousal caregivers have limitations in their own activities of daily living. Because of their complexity and frailty, the care of these veterans tends to become progressively more challenging over time.

Though most veterans enrolled in HBPC are elderly, the program is not restricted to the elderly and is also suitable for younger disabled individuals such as those with multiple sclerosis, spinal cord injuries and other diseases.

HBPC programs are able to manage an impressive array of medically complex situations. For example, HBPC teams often collaborate with pulmonary specialists to help veterans on mechanical ventilation remain at home. As of the end of fiscal year 2013, VA HBPC was being provided to 31,782 veterans every day, a 6.2 percent increase over the number of veterans served at the end of FY 2012.

OUTCOMES OF HBPC--Veterans are enrolled into HBPC for chronic, progressively debilitating conditions that are not expected to improve. Indeed, the HBPC team is doing its job if it succeeds in slowing the patient's decline.

Not surprisingly, the annual mortality rate among veterans enrolled in HBPC is 24 percent, with more than three-quarters of those deaths occurring at home. In the context of this population, patient and caregiver satisfaction is an extremely important outcome, and 82.7 percent of veterans enrolled in HBPC rate their care as very good or excellent, the highest overall satisfaction rating among all VA patient surveys.

VA conducted a national evaluation of the impact of HBPC in 2002. (4) In that year, 11,334 veterans received care in HBPC. The analysis compared total health care utilization and costs during the six months prior to HBPC enrollment with the first six months during HBPC enrollment. The analysis included the high-utilization period typical at the end of life by including veterans who died while enrolled in HBPC.

Enrollment in HBPC was associated with a 62 percent reduction in hospital bed days of care (BDOC), an 88 percent reduction in nursing home BDOC, and a 264 percent increase in homecare visits. The total cost of care was reduced from $38,000 per patient per year to $29,000 (including HBPC costs), a net 24 percent reduction.

In a subsequent analysis of all veterans newly enrolled in HBPC during fiscal year 2008, (5) enrollment in HBPC was associated with a 56 percent reduction in hospital BDOC, an 84 percent reduction in nursing home BDOC, and a 78 percent reduction in total inpatient BDOC, results similar to the 2002 analysis.

A more recent analysis (5) assessed the impact of HBPC on combined VA and Medicare utilization and costs, since many veterans are dually eligible and receive care in both systems. Including the cost of HBPC, for those veterans who received care from both HBPC and Medicare there was a 25 percent reduction in hospital admissions, a 36 percent reduction in hospital BDOC (including a 9.5 percent reduction in Medicare BDOC), and a reduction of more than 13 percent in combined VA plus Medicare total costs (including a 10.2 percent reduction in total Medicare costs).

HBPC VS. MEDICARE HOME CARE--HBPC and Medicare Home Care differ in many respects (Table 2). The fundamental difference is that Medicare Home Care is designed to provide short-term, episodic skilled care to promote recovery from specific remediable deficits. HBPC is designed to provide long-term, comprehensive continuous care for chronic multisystem disease where recovery is not an expected outcome and care often continues through the end of life.

From this fundamental difference flow many specific differences in the target population, the providers of care, the intensity and duration of care and the expected outcomes. For example, the average duration of enrollment in HBPC is approximately 315 days versus an average of 65 days for an episode of Medicare homecare. (1)

HBPC does not require a need for skilled care, does not require strict homebound status, and accepts progressive decline in function as an expected outcome. Medicare homecare requires skilled care, homebound status, and progress in recovery for rehabilitation therapy to continue.

HBPC programs have geographic restrictions (generally limited to less than 60 miles from the home VA facility) and cannot provide multiple daily or even weekly visits; the average frequency of HBPC visits is 3.1 per month. Medicare homecare can provide services in almost any location at almost any time.

Very importantly, HBPC is strongly associated with reductions in BDOC, total costs of care and high levels of patient satisfaction, whereas Medicare homecare has not shown any significant impact on BDOC or total cost of care. (5)

Also importantly, HBPC and Medicare homecare can be complementary, as when an HBPC patient with chronic illness suffers an acute illness or injury and requires skilled nursing or rehabilitation in addition to chronic care after discharge from the hospital.

INDEPENDENCE AT HOME DEMONSTRATION PROGRAM

--The success of the HBPC model and of similar programs in several smaller private sector health care systems prompted Congress to pass the Independence at Home Act in 2010.

This legislation authorizes the Department of Health and Human Services to conduct a demonstration project using home-based primary care for Medicare beneficiaries. The Independence at Home (IAH) demonstration is being conducted by the Center for Medicare and Medicaid Innovation, a part of the Centers for Medicare and Medicaid Services.

Fifteen medical practices were selected to participate in the IAH demonstration in April 2012, and an additional three consortia of practices were selected to participate in August 2012.

The selected practices and consortia will provide home-based primary care to a minimum total of 5,500 chronically ill patients for a three-year period. The program will target the highest-cost Medicare beneficiaries with multiple chronic illnesses who receive poor quality, fragmented health care. Beneficiaries retain all existing Medicare benefits and may enroll or unenroll in an IAH program at their discretion.

Care will be provided by primary care teams led by physicians and nurse practitioners and include physician assistants, social workers, pharmacists and other staff. The primary care teams will make in-home visits tailored to the individual patient's needs and preferences,

CMS will track patients' care experiences through the use of several quality measures. Practices that meet a consistent quality standard while generating Medicare savings in excess of 5 percent of total costs will receive a share of the additional savings. Medicare expects to fund the program entirely from the savings it achieves. If the demonstration project proves successful, Medicare expects to expand the IAH program nationally.

FUTURE DIRECTIONS--VA is continuing to expand the HBPC program, which is now available at 97 percent of VA Medical Centers and more than 300 outpatient facilities. VA's goal is to make HBPC available to every veteran enrolled in the VA health care system who needs that level of care.

VA is also expanding access to other services in its spectrum of noninstitutional home and community-based services, rebalancing its portfolio of services away from a past heavy reliance on nursing home care, so that veterans can remain in their homes and communities as long as possible.

The proven model of HBPC pioneered by the VA is now being tested by CMS for potentially much wider use in the Medicare program. You can expect to see this VA innovation soon in your community.

DISCLAIMER: The views and opinions in this article are those of the authors and do not necessarily reflect, and should not be taken as, official policy of the U.S. Department of Veterans Affairs.

ACKNOWLEDGEMENT: The authors appreciate the assistance of Peggy Becker, LCSW, home based primary care national program manager, in the preparation of this manuscript.

REFERENCES

(1.) Karlin BE, Zeiss AM, and Burris JF. Providing Care to Older Adults in the Department of Veterans Affairs: Lessons for Us All. Generations 34: 6-12; 2010.

(2.) Public Law 111-148. The Patient Protection and Affordable Care Act. Available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/htm

(3.) Edes T. Innovations in Home Care: VA Home-Based Primary Care. Generations 34: 29-34; 2010.

(4.) VHA Handbook 1141.01. Home-Based Primary Care Program. Available at http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1534

(5.) Beales JL and Edes T. Veterans Affairs Home Based Primary Care. Clin Geriatr Med 25:149-154; 2009.

(6.) Kinosian B, Edes T. Home Based Primary Care for Frail Homebound Veterans as a Model for Independence at Home. Journal of the American Geriatrics Society 58(4); S116, 2010.

(7.) Welsh HG, Wennberg DC and Welsh WP. The use of Medicare Home Healthcare Services. New England Journal of Medicine 335: 324-329; 1996.

* Thomas Edes, MD, MS, and James F. Burris, MD, CPE

James F. Burris, MD, is associate director for policy and planning in the Office of Research Oversight at the Department of Veterans Affairs in Washington, DC. james.burris@va.gov

Thomas Edes, MD, is executive director of geriatrics and extended care in the Office of Clinical Operations at the Department of Veterans Affairs in Washington, DC.
TABLE 1

DISEASE PREVALENCE AMONG VETERANS ENROLLED IN
VA HBPC

Disease                                  Percent of Patients
                                             With Disease

Heart disease                                    72%
Diabetes                                         48%
Depression                                       44%
Heart failure                                    35%
Dementia                                         33%
Substance abuse                                  29%
Cancer                                           29%
Anxiety/Personality disorder                     24%
Post-Traumatic Stress Disorder (PTSD)            21%
Schizophrenia                                    20%

TABLE 2

DIFFERENCES BETWEEN VA HBPC AND MEDICARE HOME CARE

VA Home-Based Primary Care          Medicare Home Care

Targets complex chronic disease     Targets remediable conditions

Comprehensive primary care          Specific problem-focused

Skilled care not required           Requires skilled care need

Strict homebound not required       Must be homebound

Accepts declining status            Requires improvement

Interdisciplinary team (every       One or multidisciplinary
time)

Longitudinal care                   Episodic, post-acute care

Reduces hospital days               No definite impact

Limited geography & intensity       Anywhere; anytime
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Title Annotation:Patient Care
Author:Edes, Thomas; Burris, James F.
Publication:Physician Leadership Journal
Date:Sep 1, 2014
Words:2027
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