James F. Brinkman, MD

1
Housecalls A Viable Option to Reach Patients
Long Term Care Integration Project Aging
Independence Services San Diego County

• James F. Brinkman, MD

2
Presentation

• Who, what, why, where, and how
• Case Study
• Challenges
• Invitation

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What I Am Not

• A Pioneer
• An M.B.A.
• A Financial Wizard
• An Expert?

4
Who I Am

• Family Physician
• M.C.O./The Toledo Hospital
• US Navy
• A-Z
• Member, American Academy of Home Care Physicians

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Why Im Here

• Medicines Trends
• Medical Economics 11/5/04 Issue
• Less Money
• More Regulation
• Less Control Catch 22

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Why

• Burnout /or Insight?

7
Why

• Less Patient-Centric
• Physicians Offices
• Hospitals
• Managed Care
• The Aging of America
• Access to Care 911

8
Where

• Patients Homes
• From RSF to shacks
• Assisted Living
• From where they beg to go to where they beg to
  leave
• SNFs
• A different world

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Where Not

• Hospitals?
• The Very Rural?
• Unsafe Neighborhoods?
• A Replacement for 911?
• NOT!!!

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How

• The Black Bag
• POS Technology
• The Office

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The Black Bag

• Standard Diagnostic Equipment
• Pulse Oximeter
• Injectables
• NTG
• TransDerm Scopalamine
• Trays/Dressings/Suture Material
• Foley Catheters/FemCaths

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The Black Bag (Cont.)

• Venipuncture (Arterial) Supplies
• Syringes/Needles
• Hemoccults
• Saline
• Betadine/Lidocaine/K-Y/Bacitracin
• Ear Lavage

13
The Black Bag (Cont.)

• Anoscopy/Headlamp
• Sharps Container
• Gloves Sterile Non-Sterile
• Batteries
• Nail Nippers
• Trauma Scissors

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The Black Bag (Cont.)

• Cell Phone
• Camera
• Digital preferred
• Organizer/PDA
• Small References
• Treo 600 SmartPhone

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The Black Bag (Cont.)

• Charts
• Forms
• EMR.

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POS Technology

• Multistix 10 SG
• Histofreezer

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POS Technology

• ECG (midmarkdiagnostics.com)
• Holter (midmarkdiagnostics.com)
• PFT (midmarkdiagnostics.com)
• ICG (bioz.com)
• iSTAT PCA (iSTAT.com)

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POS Technology

• Biosite (www.biosite.com)

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The Office

• Computer/Laser Printer
• Fax
• Scanner
• Phone
• Shredder
• Centrifuge (LabCorp)

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The Office

• Supplies
• Coding
• Billing
• Virtual Receptionist
• AccessLine.com

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Who Needs Housecalls?

• Anyone!
• Homebound
• Frail Elderly
• Acutely ill
• Disabled
• Bedbound

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Who Needs Housecalls?

• Recently Discharged from Hospital or SNF, and
  unable to get in to see their physician
• Prevent Bounce-backs

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My Model

• Solo
• No Tech
• Professional Corp. (S Corp)
• Collaborate with PCPs
• Collaborate with Hospitalists/Specialists
• Soon to add Mid-Level Providers
• PAs
• NPs

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Team/Resources

• Medicare-Covered
• IF APPROVED
• NOT Medicare-Covered

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Team MC-Covered

• Home Health/Hospice Agencies
• RN/LVN
• PT/OT/ST
• CHHA
• MSW
• Dietitian
• Chaplains/Volunteers

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Team MC-Covered

• Oxygen/Respiratory Support DME
• Pacific Pulm. Svcs.
• Nocturnal Oximetry
• Oxygen
• Nebulizers
• Progressive Medical
• Cough Assist
• Ventilators
• TXP

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Team MC-Covered

• Radiology
• Mobile
• BioPath
• Non-Mobile
• Ultrasound (CVT)
• Echo
• Abdominal
• Extremity, (AV)

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Team MC-Covered

• Pharmacy
• Delivery vs. Pick-up vs. Mail-Order
• Compounding
• IV Option Care
• Resp MedMart

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Team MC-Covered

• DME
• Beds, including home Clinitron
• Air-Mattress Overlays
• Commodes
• Walkers/Canes
• Scooters
• Trapezes

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Team MC-Covered

• DME
• Suction
• IV Pumps
• Nutrition Pumps

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Team MC-Covered

• Ambulance
• AMR
• Balboa

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Team NON-MC-Covered

• Patient
• CGs/Spouses/Family
• Case/Care Managers
• Elder Care Attorneys
• Fiduciaries/Conservators
• DPOAHCs

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Team NON-MC-Covered

• Community-Based Organizations
• APS/Senior Team
• IHHS
• Meals-On-Wheels
• Police/Fire/Rescue Personnel
• Lifeline/SafeReturn
• Medical Alert Bracelets
• Companion Canines

34
Team NON-MC-Covered

• Marcia
• The Great Physician

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Case Studies

• W.B.
• 80 yo WF
• Bedbound since 1991 s/p Laminectomy, post-op
  Cord Hematoma caused paraplegia
• 1 mo. Later Hemorrhagic CVA, had craniotomy
  resulting L. Spastic Hemiplegia

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Case Studies

• W.B.
• HTN
• Dementia
• Cardiomyopathy
• Chronic Pain
• DJD
• Spasms
• RSD
• Neurogenic Bladder

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Case Studies

• W.B.
• Chronic Tinea Pedis
• Cellulitis
• Hx. Urosepsis
• Hx. Decubiti
• Chronic Constipation
• Requires digital extraction q 3-4d

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Case Studies

• W.B.
• Lives in SFD
• 24/7 CG
• HH
• Foley
• Air-Mattress Overlay

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Case Studies

• W.B.
• Avoided ED Visits Hospitalizations for
• Urosepsis
• CHF
• Impactions
• Clogged Foleys

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My Role

• PCP Quarterback
• Call Run the plays
• Rely on my Front Line
• Sometimes I Pass or Handoff the Ball
• Sometimes I Run the Ball
• Most of the time We Score!
• Rarely, We Punt.

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Role of The Physician/Provider

• Member of Interdisciplinary Team, not above it
• Assess, Treat, Prescribe, Certify and Monitor
  Home Visits and Care
• Care Plan Development and Oversight
• Evaluate Quality of Care

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Role of The Physician/Provider

• Communicate and Coordinate
• With Patient
• With Family
• With Care Manager and the Multitude of other Team
  Players

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My Goals

• As long as its feasible and appropriate
• To keep patients at home
• To keep patients out of the ED hospital
• To keep patients as independent as possible
• To keep the family together
• To rally as many resources as I can to help
  accomplish that
• To provide compassionate, thorough, dignified care

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My Goals

• Recognize that sometimes its
• Not Feasible
• Not Appropriate

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Benefits Of Medical Housecalls

• Improved Access to Care
• Prevent Unnecessary Hospitalizations
• Prevent Unnecessary ED Visits
• Improved Health Outcomes
• Improved Quality of Life

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Benefits Of Medical Housecalls

• High Patient Satisfaction
• Regardless of age, surveys indicate Pts. prefer
  to be cared for in the home
• More comfortable in their own home
• More likely to be compliant

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Benefits Of Medical Housecalls

• High Family Satisfaction
• Reduced Stress!
• Improved Logisitics
• Less time lost from work/job

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Benefits Of Medical Housecalls

• Cost-effective vs. repeated ED Visits and
  Hospitalizations
• Technology allows far more POS diagnosis and
  procedures than previously available

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Challenges Barriers

• Managed Care
• Medicare
• Medi-Cal
• 3rd Party Payors

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Challenges Barriers

• Malpractice
• Declining Reimbursements
• Increasing Expenditures
• Increasing Federal, State, and Local Regulation

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Challenges Barriers

• Disparities between fee schedules for Home Visits
  and AL

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Challenges Barriers

• Different Models
• CMS and Congress may not do what we want they
  often do what they want
• Changing Legislation

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Challenges Barriers

• Traffic
• Weather
• Geographic Distribution
• The Price of Gas
• Travel not Reimbursed
• Fewer patients seen each day

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Challenges Barriers

• Other housecall providers can have negative
  reputations
• Office-based and Hospital-based Physicians dont
  know what we can do
• Marketing
• Best Word-of-mouth from HHAs and
  Patients/Families

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AAHCP

• American Academy of Home Care Physicians
• Provide
• Leadership
• Resources
• ListServe
• Political Support and Lobbying
• Limited Marketing
• Professional Fellowship and Education

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AAHCP

• Open to
• Physicians
• Midlevel Providers
• Et al.

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AAHCP

• www.aahcp.org

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Invitation

• Why arent you on staff at a hospital?
• The wrong question!
• Why arent your current doctors doing housecalls?
• Why arent the hospitalists doing housecalls?

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Invitation

• Why isnt there better coordination of care
  between all levels of providers?
• Hospitalists
• Office-based
• Housecall Physicians

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Invitation

• Why doesnt Managed Care get it?

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Invitation

• Why not YOU?
• Join the AAHCP
• Check out the resources
• Consider building housecalls part-time into your
  practice