The Medical House Call Program at the Washington Hospital Center

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The Medical House Call Program at the Washington
Hospital Center
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Philosophic DifferencesPatient-Centered Care

• Built to meet the needs of high-cost users
• Negotiated medical care plan
• Shared responsibility for compliance
• Self-care education
• Specialists
• Non-covered services ophthal, procedures, etc
• Covered systems nearly all others

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Philosophic DifferencesPopulation Health Model

• Informal, but legally binding contract
• Responsible for the total health and well-being
  of a set group of patients (in a defined
  geographic area)
• Primary Care Physician led Team is thefirst to
  be called for all health related matters

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A House Call Team

• Team Members
• Two Geriatrician M.D.s (0.5 FTE each)
• Two NPs (2.0 FTE)
• Social worker
• Coordinator
• Clerical Assistant
• Horizontal Team hierarchy
• Covers 300-350 lives

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A House Call Team

• Weekly team meeting (90 minutes)
• Discuss new and complex patients
• Communication with VNA pharmacy / DME
• Review and refine upcoming schedules
• Home Care/ DME/ Billing documentation
• Multiple lines of communication
• From multi- / inter- / trans-disciplinary
• Shared ownership and responsibility

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A House Call Team

• Scheduled visits based on the trajectory of
  illness
• Confirm visits 1 day before
• Organized by geography
• Strict limits on catchment area
• Clinician routing

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The House Call Visit

• Semi-structured encounters
• Evidence-based diagnostics and therapy
• Intuitive / Current issues
• Patient / Caregiver education in DM
• Coordination
• Specialty referrals
• Community-based supportive interventions
• Monitor and treat according to the patients
  condition, prognosis and goals

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On-Demand Scheduling

• Physician phone availability 24/7
• Flexible scheduling
• Build in space for urgent visits (1-24 hrs.)
• On-the-fly scheduling

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Portable Technology
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Portable Technology

• House Call Clinicians Modern Black Bag

• Full range BP cuffs
• Oto/Ophthalmoscopy
• Electronic scale
• Nail care / debride
• Phlebotomy
• iSTAT blood analyzer
• Portable EKG/ X ray

• Pulse oximetry
• Spirometry
• Vascular doppler
• Wound debridement
• Disimpaction tech.
• PEG replacement
• Digital photography

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Managing Urgent and Acute Care

• Timely and effective primary care that reduces
  the risk of hospitalization
• Continuity ? Better management
• Earlier intervention in an acute exacerbation
• Acute episode addressed in the context of
  underlying co-morbidities andrespectful of the
  patients wishes

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Acute Care

• Geriatrics Unit to serve as Home Base
• How to ensure admits to sponsor hospital
• 24/7 availability
• Perform urgent house calls
• Relationship with EMS ambulance service
• Arrange direct admissions or tagged in ED
• Provide the acute care

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Elderly Medicaid Waiver

• Washington DC EPD Waiver Program
• Designed to prevent (or delay) NH placement
• Patients may have income up to 300 of the
  federal poverty level
• Requires assistance with ADLs IADLs (nursing
  home eligible)

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Elderly Medicaid Waiver

• Supportive services included in program
• PCA
• Case management
• Prescription assistance
• PERS (Lifeline)
• Respite

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Making It WorkReal World Outcomes

• One good example
• is worth a thousand theories.
• Lawrence Summers
• President, Harvard University

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Patient Data Insurance
Source WHC MHCP 2003
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Patient Data Gender
Source WHC MHCP 2003
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Patient Data Race
Source WHC MHCP 2003
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Outcomes

• Program growth success (2 Full Teams)
• Enroll 10 to 15 new patients / month
• gt1300 total patients enrolled in program
• Currently care for about 500 patients
• 338 admissions to WHC in 2005 (_at_ 475) Median LOS
  5 days

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Terminal Care

• Recognizing the transition from chronic to
  terminal conditions
• Build trust end of life goals over time
• Understand values of patient/family
• Palliative care
• Hospice versus Hospice-Lite

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Site Mode of Death
Source WHC MHCP 2003
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Whats Next

• Enhanced Urgent Care Services
• Extended hours
• High tech capabilities Dx Tx
• In-home end-of-life care (vigil services)
• Patient-Centered EMR
• Single record for out and in-patient care
• Shared with other providers
• HHA
• Pharmacy
• Team Expansion

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Life Care Coordination Fees

• Layered fee for non-covered services
• Comprehensive Geriatric Assessment
• Team meetings
• Care coordination
• Enhanced urgent care services
• On-call services
• Gap-filling fund
• Renewable contingent on performance
• Adherence to evidence-based guideline targets
• Patient and caregiver satisfaction targets
• Reduced costs

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Key Elements to System Reform

• A physician-led, interdisciplinary primary care
  team under a fee-for service system of care
• Patient-centered design
• across settings of care
• provide continuity over the natural history of
  illness
• Management requires coordination of services
• caregiver support
• advance care planning
• a restructuring of the payment system

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