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

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Home Based Chronic CareSteven L. Phillips, MD,
CMD2005 AGS Annual MeetingOrlando,
Floridastevenlp_at_charter.net
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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

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A Century of Change
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Americans Current Health Care Expenditures
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Change in the New Century
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(No Transcript)
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Trajectories of Chronic IllnessService Needs
Across Time
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Short Period of Evident DeclineMostly Cancer
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Long-Term Limitations with Intermittent Serious
EpisodesMostly Heart Failure and Lung Failure
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Prolonged DwindlingMostly Dementia, Disabling
Strokes, Frailty
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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

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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

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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

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Current System Organized by Setting

• Hospital
• Nursing Facility
• Home
• Doctors Office

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Impedes continuity of care across settings and
across the changing challenges of worsening
illness
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Clinical Care Model

• Physicians
• Advanced Practitioners of Nursing
• Physician Assistants
• Licensed Clinical Social Worker
• Nurse Case Manager
• Clinical Pharmacist
• Therapists

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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
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Spreading the Risk

• Go Where They Reside
• Maximize Other Resources
• Minimize True Exposure

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SENIOR DIMENSIONS CHRONIC HOME CARE

• Program Intent
• Definition of Client
• Guidelines for Assessment
• Recertification of Services
• Effectiveness of Program
• Potential for Replication

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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

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Definition of Client

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

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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
  

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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

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Guidelines for Assessment

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

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Guidelines for Assessment

• Social Support
• Environmental Safety
• Functional Ability
• Available Community Resources

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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?

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Effectiveness of Program

• Audit Reviewed Utilization of
• Acute Hospital Days
• Subacute Days
• Skilled Days

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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

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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

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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

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Potential for Replication

• Adequate Financing
• Provider Education
• Client and Family Acceptance

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Poster Abstract D 108 AGS-2005T. 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

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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

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Criteria for Home-BasedChronic Care Program

• Risk for Recurrent Hospitalization
• Arduous to Leave Home Without Assistance of
  Device or Another Person
  
• Neither Skilled nor Strict Homebound Status
  Required

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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

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Home-Based Primary Care Team

• Nursing
• Social worker
• Rehab Therapists---PT/OT
• Dietitian
• Physician---Oversight and Visits PRN
• Administrative and Pharmacy Support

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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

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Prevalence of Diagnosis

• Heart Disease 72
• Diabetes 53
• Heart Failure 26
• Chronic Lung Disease 23
• Stroke Deficit 15

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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

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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