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How to Start and Manage a House Calls Program in an - SGIM

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HowВ toВ StartВ andВ ManageВ aВ HouseВ CallsВ ProgramВ inВ anВ AcademicВ InstitutionВ withВ aВ FocusВ onВ TeachingВ Trainees
SGIMВ В NationalВ MeetingВ 2008
AprilВ 9,В 2008
Faculty
• Precourse Coordinator: – Linda DeCherrie, MD – Mount Sinai School of Medicine
• Faculty:
Peter Boling, MD – Virginia Commonwealth University
Serena Chao, MD, MSc – Boston University Medical School
*Peter Gliatto, MD – Mount Sinai School of Medicine
Jennifer Hayashi, MD – Johns Hopkins University School of Medicine
– Sharon Levine, MD – Boston University Medical School
– Theresa Soriano, MD, MPH – Mount Sinai School of Medicine
–
–
–
–
*UnableВ toВ beВ present
Question
• What were you hoping to learn today?
• What are the biggest pressures you face at your institution regarding starting or maintaining a home care program?
HomeВ CareВ HistoryВ andВ Policy
PeterВ A.В Boling,В MD
ProfessorВ ofВ Medicine
VirginiaВ CommonwealthВ University
HomeВ Care:В AВ PatientВ View
Con’s
Pro’s
•
•
•
•
•
•
•
•
FoodВ choices,В smells
Company,В familiarВ faces
Schedule
FreedomВ ofВ choices
Activity,В mobility
Privacy
Sleep
FewerВ misadventures
•
•
•
•
•
DisruptsВ household
StrangersВ inВ theВ house
CaregiverВ workload
UnfamiliarВ tasks
Medicalizing the home • Expense
LTCВ PopulationВ (1990)
• 42.6 million (16%) physical or mental disability
• 12.6 million require LTC (ADL or IADL assist)
500,000В children
4.8В millionВ disabledВ youngerВ adults
7.3В millionВ elderly
• 42% are under age 65
• Only 2.3 million institutionalized
Vladeck.HCF Review.1997
WhoВ AreВ TheВ ChronicallyВ Homebound?
3 or more ADL’s (1980’s)
Children
400,000
Young Adults
475,000
Elderly
750,000
1.6 million
Source: Boling, 1997
In the Beginning There Were…
PhysicianВ Housecalls
• Hippocrates: into whichever house I may enter
• 1965:  Internists made 4.8 visits per week
• 1966:  NY pediatricians made 15 per week
• 1976:  NJ family physicians made 6 per week
• 1990:  Internists (44%) made 6 per year
FamilyВ physiciansВ (65%)В madeВ 10В perВ year
• 1990’s: Medicare = 1.5 million visits per year
In‐Home Nursing
• Parish nursing and checking services (1900)
– Epidemic infectious diseases
• Medicare (1965): growth of skilled care
• Testing new high tech models (1970’s)
– Home dialysis
– Home IV therapy
– Home ventilator care
• Staggers lawsuit (1980s): growth accelerates:
MedicareВ HomeВ HealthВ AgencyВ Payments
$ Billions
18
16
14
12
10
8
6
4
2
0
Staggers lawsuit
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
1993В RegionalВ Variation
MedicareВ HomeВ HealthВ Visits
Visits per 1,000 Medicare beneficiaries
13460
TN
12350
MS
11130
LA
MN
1825
HI
1744
1425
SD
0
2000
4000
6000
8000
10000
12000
14000
16000
HomeВ HealthВ SpendingВ UnderВ BBA
14
BBA
12
10
$ Billions 8
6
4
2
0
1991 1992 1993 1994 1995 1996 1997 1998
Medicare
Out of Pocket
Medicaid
CBOВ Estimates:
BBAВ ChangesВ forВ HomeВ Health
• Initial (1997)
– $16.1 billion reduction over 5 years
– made at the time of writing BBA
• Revised (3/2000)
– $70 billion reduction • Heaviest proportionate reduction of major health care market sectors
MedicareВ HomeВ HealthВ PPS
October,В 2000
•
•
•
•
•
•
•
60В dayВ episodes
OASIS‐B data (23 of 89 items)
80 category case‐mix model (HHRGs)
SocialВ variablesВ veryВ smallВ role
Roughly 5‐fold payment range Mean payment in 2000 = $2,115.30
PT/OTВ (>10В hours)В hasВ majorВ impact
MedicareВ HHAВ Payments
1997 BBA
$ Billions
18
16
14
12
10
8
6
4
2
0
1985 1987 1989 1991 1993 1995 1997 1999 2001
MedicareВ HomeВ Health
Changed payment method
80
60
40
20
66
72
74
73
51
41
36
Clients
Visits/client
30
29
0
1994 1995 1996 1997 1998 1999 2000 2001 2002
Percent
MedicareВ HHA:
HospitalizationВ Rate
28.1
28
27.9
27.8
27.7
27.6
27.5
27.4
27.3
27.2
27.1
2000
2001
2002
2003
2004
WhenВ areВ HHAВ PatientsВ (28%)В В HospitalizedВ ?
80
70
60
50
Percent 40
30
20
10
0
1 week
2 weeks
3 weeks
Time to hospitalization
1 month
Hospitalization, Medicare HHA’s
% hospitalized (agency level data)
50
40
30
20
47.4
29.0
10
17.3
0
Worst 25%
Median
Best 25%
Apr '03 - Mar '04
National risk-adjusted rates, based on 2003-4 OASIS data
Post‐acute Care Readmits (1997)
Percent Readmitted to Hospital
Diagnosis
< 1В day
< 30В days < 60В days
HipВ replaced
1.0
8.1
11.7
HipВ fractured
1.1
12.1
18.4
Pneumonia
1.9
16.2
21.1
Stroke
3.3
15.5
22.8
COPD
1.7
18.4
21.1
CHF
3.6
23.3
34.0
Kane RL. Health Services Research. 2002; 37(3):667
PhysicianВ paymentВ andВ MedicareВ houseВ calls
House calls pay
increased
2.5
Dom care pay
increased
2
1.5
House calls
Dom Care
1
0.5
06
20
98
19
19
95
0
HomeВ CareВ Certification
• New in 2001
• For physician
• not for NP/PA
•
•
•
•
MedicareВ skilledВ homeВ healthВ care
HCPCSВ codes
G0180 (Certification) – about $70
G0179  (60‐day Re‐certification) – about $60
CareВ PlanВ Oversight
• Patient is receiving skilled services
• 30 minutes per month of physician work
OR
• 30 minutes per month of NP work
• Documented effort overseeing skilled care
• Face‐to‐face contact within past 6  months
WhoВ WillВ BeВ TheВ CaseВ Manager?
Вѓ
Вѓ
Вѓ
Вѓ
Вѓ
Вѓ
Вѓ
Patient/familyВ member
Physician/nurseВ practitioner
HomeВ healthВ agency
CommunityВ serviceВ agency
Insurer/payer
PharmaceuticalВ company
PrivateВ adviser/counselor
Who May Be “Left Out”
Вѓ
Вѓ
Вѓ
Вѓ
Вѓ
Complex, high‐cost cases in Medicare PPS Patients living in less affluent areas
Those that can’t afford out‐of‐pocket costs
ThoseВ withВ weakВ socialВ supports
ThoseВ withВ lowerВ endВ payers
Вѓ MedicaidВ patientsВ withВ chronicВ illness
Вѓ VariesВ considerablyВ byВ state
MedicareВ PartВ AВ Payments
Hospital
DRG’S
Nursing
Home
RUG’S
Home
Care
PPS
AВ Life
Birth
Marriage
Age 50
Retirement
Death
Episodes of
Serious Illness
OneВ Year,В ChronicВ Illness
18 days in hospital, 35 days in NH
…… 312 days at home
Hospital:
A-fib, Stroke
6 days
Nursing
Home Stay
35 days
Hospital:
MI, CHF
Hospital:
CHF
4 days
8 days
Home Health
Episodes
45 days
28 days
62 days
Beware “Scope Creep”
Medical Care
EvidenceВ Review:
CanВ HomeВ CareВ MakeВ aВ Difference?
PeterВ A.В Boling,В MD
ProfessorВ ofВ Medicine
VirginiaВ CommonwealthВ University
RochesterВ HomeВ MedicalВ Team
• RCT, late 1970’s, 150 patients per group
–
–
–
–
HospitalВ costsВ 38%В lower
OutВ ofВ homeВ costsВ 39%В lower
In‐home costs 61% higher
TotalВ costsВ 9%В lowerВ (notВ significant)
• Terminal patients
– Total cost 31% lower (significant)
– see J Am Geriatrics Society. 1984; 32:288
• Satisfaction improved, but not health status
Zimmer. AJPH. 775:134; 1985
National VA HBPC Study (1994‐8)
• RCT with 1,966 patients in 16 HBPC sites
• Targeted: mean age 70, >2 ADLs, terminal, CHF, or COPD
• Outcomes:  function, HR QoL, satisfaction, caregiver burden, hospital use, costs
• Variable implementation/intensity of care
• Satisfaction and QoL improved
• Utilization and costs: no change or increased
JAMA: 2000; 284(22):2877
MultidisciplinaryВ InterventionВ toВ PreventВ CHFВ Readmissions
• Nurse‐directed team
– Patient education, home care, phone calls
– Geriatric cardiology consult in hospital • Age 70 + admitted for CHF (high risk)
– Uncontrolled hypertension or ischemia
– 3 or more admissions in past 5 years
• RCT: 142 study vs. 140 controls
– 90‐day CHF re‐admissions 24 vs. 54
– QoL scores improved
– Average cost $460 lower (in 1994 $)
Rich et al. New Engl J Med 1995; 333:1190
PreventiveВ ElderВ Care
•Age over 74, live at home in Santa Monica
•Exclude: severe dementia, going to NH, terminally ill, severe functional impairment, language barrier
•RCT: 215 intervention, 199 usual care
•1.0 NP and 0.1 geriatrician per 136 patients
– NP quarterly for 3 years, feedback to pt and PCP
– Geriatrician review
– 47% of recs followed
Stuck AE et al. NEJM. 1995; 333(18): 1184-89
PreventiveВ ElderВ Care
•
•
•
•
•
•
•
LessВ ADLВ dependence,В interventionВ group
128В vs.В 820В chronicВ careВ nursingВ homeВ days
MoreВ outpatientВ physicianВ visits
SimilarВ communityВ serviceВ use
SimilarВ acuteВ careВ andВ shortВ termВ NHВ days
SimilarВ deathВ ratesВ (11%В vs.В 13%)
“Cost‐effective”‐ ($35 prevented 1 NH day)
Stuck AE et al. NEJM. 1995; 333(18): 1184-89
The Effect of Preventive Home Visits: A Meta‐analysis
• 18 studies qualified: 13,447 elderly subjects
• Home care reduced NH use if:
– Multi‐dimensional geriatric assessment
– Multiple F/U home visits: (>9 visits: AOR=0.66)
• Functional decline lessened
• Target persons at lower risk for death
• Survival benefit for young‐old not old‐old
Stuck. JAMA. 2002; 287(8):1022
FallВ Prevention
• Controlled trial, two MD groups
• Age > 69, ambulatory, not in NH, MMSE >19, no exercise, > 1 fall risk
• 1,950 screened, 355 eligible, 301 agreed
• 153 Intervention vs. 148 Usual Care
Medical Care. 1996. 34(9):954
CumulativeВ Percent:В PatientsВ withВ OneВ orВ MoreВ Falls
Tinetti M., et al. NEJM 1994;331:821
CostsВ ofВ Care:В FallВ Prevention
All subjects
Highest Risk
Lower Risk
Hosp
UC
(140)
7802
INT
(148)
5430
UC
(81)
11579
INT
(75)
7509
UC
(59)
2616
INT
(73)
3296
NH
752
212
392
419
1246
0
Home
282
183
467
59
29
311
Study
0
894
0
960
0
827
Mean
10439
8310
14232
10537
5232
6026
2619
1872
2853
1318
2506
Median 1534
Medical Care. 1996. 34(9):954
NaylorВ 1999В TransitionalВ CareВ Study
• RCT at U. Penn
• Enrolled < 48 hours after hospital admit
• 186 control  • 177 intervention •
•
•
•
MeanВ ageВ 75
AverageВ ofВ 5В medicalВ problems
57%В fairВ toВ poorВ baselineВ health
AdvanceВ practiceВ nurseВ intervention
Naylor et al. JAMA. 281(7):613; 1999
Eligibility
1. AdmissionВ diagnosis
•
•
•
•
•
•
•
•
2. Risk for poor post‐
CHF
Angina
MI
Resp.В infection
CABG
ValveВ В replacement
MajorВ bowelВ procedure
OrthoВ procedure,В lowerВ extremity
Naylor et al. JAMA. 281(7):613; 1999
dischargeВ outcomes
•
•
•
•
•
•
•
•
•
AgeВ >В 80В yrsВ WeakВ supportВ system
ChronicВ healthВ problems
Depression
FunctionalВ impairment
MultipleВ hosp,В 6В months
Hosp.В inВ pastВ 30В days
Fair/poorВ healthВ (perВ pt)
Non‐adherence
• Control
– standard discharge planning
– HHA services if referred
• Intervention
– gerontological APN’s
– discharge planning, phone contact
– home visits for 4 weeks (minimum = 2)
HHA nurse visits
APN visits
Naylor et al. JAMA. 281(7):613; 1999
Intervention
3.1
4.5
7.6
Control
7.1
0.0
7.1
Re‐admissions
When Re‐admitted
InterventionВ (n=177)
ControlВ (n=186)
P‐value
0 – 6 weeks
17
32
<.001
6 – 24 weeks
32
60
.02
TotalВ days
270
760
<В .001
Days/ptВ 1.53
4.09
<В .001
Days/re‐admit
7.50
10.1
<В .001
TimeВ inВ HospitalВ Naylor et al. JAMA. 281(7):613; 1999
CostsВ inВ DollarsВ UtilizationВ category
InterventionВ (n=177)
ControlВ (n=186)
P‐value
Re‐admits
427,217
1,024,218
<.001
OtherВ acuteВ care
34,075
37,721
.74
Nurses
101,697
101,049
0.72
Other
79,606
75,940
0.70
Total
642,595
1,238,928
<В .001
Mean/patientВ 3,630
6,661
<В .001
Hospital
HomeВ visits
Naylor et al. JAMA. 281(7):613; 1999
Percent
MedicareВ HHA:
HospitalizationВ Rate
28.1
28
27.9
27.8
27.7
27.6
27.5
27.4
27.3
27.2
27.1
2000
2001
2002
2003
2004
WhenВ areВ HHAВ PatientsВ (28%)В В HospitalizedВ ?
80
70
60
50
Percent 40
30
20
10
0
1 week
2 weeks
3 weeks
Time to hospitalization
1 month
Hospitalization, Medicare HHA’s
% hospitalized (agency level data)
50
40
30
20
47.4
29.0
10
17.3
0
Worst 25%
Median
Best 25%
Apr '03 - Mar '04
National risk-adjusted rates, based on OASIS data
OutcomeВ EvaluationВ inВ MedicareВ HomeВ HealthВ Care
• OASIS
– 89 item assessment (at open and close)
– 25 item subset (every 60 days)
– Risk‐adjusted quality reports
– 41 quality indicators
– PPS payment (23 of 89 items)
– Public reporting (Home Care Compare)
• OBQI (Outcomes‐Based Quality Improvement)
OBQIВ Demonstration(s)
• 2 concurrent demonstrations
• National: 54 HHA’s, 26 states, 3 years
– 157,548 cases
• New York: 19 HHA’s, 4 years – 157,917 cases
• Controls: 248,621 cases
• Each agency chose 2 endpoints:  (1) hospitalization and (2) a clinical condition
• Feedback to HHA on outcomes, compared to national pool, case‐mix adjusted
J Am Geriatr Soc. 2002; 50:1354
OBQIВ Demonstration
• Decline in hospitalization
– 22% per year (national)
(33%В toВ 29%В toВ 25%)
– 26% per year (New York)
(28%В toВ 26%В toВ 23%В toВ 22%)
• Clinical outcomes
– Targeted: improved 5 ‐ 8%
– Not targeted ~ 1% (no change)
J Am Geriatr Soc. 2002; 50:1354
TotalВ HealthВ CareВ Cost
Health Care Cost
Per Patient Per Year
BeforeВ vs DuringВ HBPC; ColumbiaВ MOВ VAMC,В 1994
50000
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
VERA Allocation
Cost before HPBC
Cost During HBPC
Total Annual health Care Cost per patient (n=30), contrasted with the VERA
allocation of approximately $33,000/patient/year for t heir care. The cost of health
care for the 6 months prior to enrollment in Home-Based Primary Care (HBPC) is
compared with the cost of care while in HBPC. The cost of HBPC is included.
T Edes. JAMA 1999; 282: 1129
2002В UtilizationВ BeforeВ vs DuringВ HBPC
AllВ HBPCВ programs;В n=11,334
CareВ daysВ orВ visitsВ perВ patientВ perВ year
HospitalВ BDOC
BeforeВ HBPC
14.8
DuringВ HBPC
5.6
Change
‐ 62% P < 0.0001
NursingВ homeВ BDOC
OutpatientВ visits
AllВ homeВ careВ visits
26.8
3.2
‐ 88%
31.6
32.2
+В 2%
20.6
73.8
+В 264%
CostsВ ofВ CareВ BeforeВ vs DuringВ HBPC (perВ patientВ perВ year)
TotalВ CostВ ofВ VAВ Care
Hospital
BeforeВ HBPC
$38,168
DuringВ HBPC
$29,036*
Change
‐ 24% P < 0.0001
$18,868
$7026
‐ 63%
$10,382
$1382
‐ 87%
Outpatient
$6490
$7140
+В 10%
AllВ homeВ care
$2488
$13,588*
+В 460%
NursingВ home
ElderPaCCT:В В Housecall ProgramВ withВ AreaВ AgencyВ onВ Aging
• ElderPACT (n=49), controls (n=100)
• Matched cohort; functional outcomes at 1 year; total costs at 1 and 2 years
• Medicare costs were lower by half
– Year 1    $17,409
– Year 2    $11,255
vs.В В В В $35,992
vs.В В В В $22,868
• NHP from community lower
• Hospitalization (1 year)
– 2.1% per month vs. 5.7% per month
Kinosian. J Am Geriatr Soc. May 2004 - poster
GRACEВ RCT
•
•
•
•
•
•
LowВ incomeВ seniorsВ (340В perВ group)
NPВ andВ socialВ workВ team
FoundВ largeВ numbersВ ofВ newВ problems
Improved SF‐36 globally, small effect size
LittleВ changeВ forВ individualВ outcomes
LittleВ changeВ inВ healthВ careВ costs
– Possible favorable effect on sicker subgroup
Counsell JAMA 12-07
Counsell, JAMA 12-07
Counsell
Dying Year After Spouse was Hospitalized
Risk of Dying
SpouseВ hosp.В for
Cancer
Pneumonia
CoronaryВ disease
Stroke
COPD
HipВ fracture
Psychiatric
Dementia
MaleВ partner
0.86 – 1.08
1.05
1.06
1.06
1.12
1.15
1.19
1.22
Adapted from New Engl J Med. 2006; 354:719
FemaleВ partner
0.96 – 1.14
0.97
1.06
1.05
1.13
1.11
1.32
1.28
EligibleВ forВ CareВ Coordination
• 4 complex medical conditions + >1 ADL or IADL
• Cognitive + >1 ADL or IADL
• >3 complex medical or cognition + > 1 ADL or IADL
• 427,000 (1.3%)
• 1.42 million (4.2%)
• 1.97 million (5.8%)
J Am Geriatric Soc. 2005; S3:2051-2059
BU Geriatrics Home Care
Program
Serena Chao MD MSc
Boston University Medical Center
Home Care Program: Origins
• 1875: Home Medical Service
established
• 1970s: University Hospital Home
Medical Service switched focus to
geriatric population
• 1980s: City Hospital developed a
Geriatrics and Home Care program
– Interdisciplinary team model
Home Care Program: Origins
• 1994: UH and CH home care programs
merged
– Interdisciplinary team model preserved
• 1996: UH and CH merged to become
Boston Medical Center
Institutional Funding
• Large subsidy from BMC
• Support is historic
• Home Care program fulfills primary
mission of BMCÆ to provide health
care to the underserved
BU Home Care Program
• 19 providers
– 6 MDs
– 5 Advanced Practice Nurses (APNs)
– 6 NPs
– 1 social worker
– 1 resource nurse
• 580 patients: homebound frail elders
Eligibility
Urgent Visits
• Telephone Medicine: provider team
calls patient, family, caregiver, VNA
• If home visit is felt to be necessary:
member of patient’s MD/APN/NP team
sees patient within 48 hours
Travel
• Providers own car
• Some neighborhoods parking can be
challenging
Safety on Visits
• Detailed Home Care Security Policy
• Providers must tell someone else they
are making home visits
• All must carry cell phones
• If providers feel uncomfortableÆleave
• Safety lecture every 1-2 years given to
staff by a Personal Safety Consultant
Technology
• All providers take a laptop with wireless
internet connection
– Access to BMC electronic medical record
JohnsВ Hopkins
ElderВ HouseВ CallВ Program
JenniferВ Hayashi,В MD
Origins
• Started in 1987 as practical response to clinical problem for older patients who could not make it into office
• Housestaff part of program from the beginning
InstitutionalВ funding
• Overhead/staffing
• Faculty (mostly part‐time)
• “Joint agreement” with medical center
NumberВ ofВ providers
• Staffing:
– 1 faculty
– 1 fellow
– 12 GIM residents
– 1 LPN
• Number of patients: ~130
Eligibility
• Catchment area around hospital
• Difficulty getting to doctors office
• > 65 but exception are made on need
UrgentВ visits
• Weekdays only
• Depending on faculty/fellow availability
• Try to see within 1‐2 days
Travel
• Car
• Motorcycle
Safety
• no incidents
• Instructed to be aware of environment • Technology
– Administrative: handheld tape recorder
– Clinical: usual suspects (EKG, pulse ox)
Technology
• Administrative: handheld tape recorder for dictation
• Clinical: EKG, pulse ox
• Labs: drawn by provider unless open to skilled nursing; also team has LPN who will go out to draw labs
• Xrays: private company
VCUВ HouseВ CallsВ Program
PeterВ A.В Boling,В MD
ProfessorВ ofВ Medicine
VirginiaВ CommonwealthВ University
ProgramВ Beginnings
• 1984
–
–
–
–
UnmetВ clinicalВ need
SoloВ practiceВ asВ juniorВ facultyВ (0.5В FTE)
VisitedВ otherВ programsВ toВ studyВ models
ClinicВ ptsВ (stretchers,В wheelchairs,В walkers),В n=75
• 1986
– Case control study with hospital administrator
• Reduction in costs from LOS
• Avoid un‐reimbursed bounce‐backs
– Hospital funding
• Secretary, 2 NPs, 0.5 FTE Social worker
AcademicВ Beginnings
• Connections
– Knight Steel
– Joe Keenan
– Paul Hankwitz
– Sheldon Retchin
• National physician survey
– Internal small grant
• SGIM workshop
– 1987 annual meeting in San Diego
BuildingВ theВ CoreВ Group
• Physician‐NP team model
• Key issues:
– Finding physician partners
– Teaming
• Forming, storming, norming performing
• Relationships with community resources
• Defining program role(s)
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–
–
–
AccessВ forВ healthВ systemВ pts,В thenВ community
Post‐hospital care, care coordination
15В mileВ radius
Education
Eligibility
•
•
•
•
•
<В 15В milesВ fromВ hospital
Adult
AcceptВ HouseВ CallsВ forВ primaryВ careВ HomeboundВ byВ illnessВ (noВ convenienceВ care)
CapacityВ inВ program
– Waiting list
Staffing
• Shared with other geriatric programs
• MD FTEs
– 1.5
• NP FTEs
– 2.5
• Clerical staff
– 1.5
• Administrator
Services
• Census = 250 ‐ 270
• Regular visits: average monthly
• Geographic routing for efficiency
UrgentВ visits
• Episodic: about 25% of visits
• Weekday service only
• After hours on call: phone only (not many)
Safety
• Providers travel alone
• Exclusions for safety: 1 case every 2‐3 years
Technology
• Labs come back to hospital
– Use HHA for some labs
• X‐ray, EKG, doppler: order out
– Mobile PACS now available
• Pulse ox
• Pvt. pharmacy picks up C‐2 hard copies
• Wireless EMR via health system (2008)
HealthВ SystemВ Integration
• Address the needs of your customer (s)
– Hospital provides us $$ support
• Transitional care (2000)
– Short term house calls post hospital
– 73% of pts return to PCP, 13% enroll in House Calls
• Accept pts from ambulatory care clinics
• Serve families of health system employees
• HMO Special Needs Program (2008)
– VCUHS Medicaid HMO added SNP program
Accreditation
• Joint Commission
– Home care organization
– Separate survey from main medical center
– 1997 = first survey
– Very successful record
– Significant cost (effort and $)
Financing
• Clinical receipts
• Included in the array of geriatric programs
– House calls, nursing home, transitional care, consults, ambulatory care
– ~ $425,000 / year hospital  funding (all programs)
– Expanded with nursing home program (1996)
• Medical school support for education
• Grants: come and go
– Need core support for program continuity
AdministrativeВ Study
• House Calls patients at VCU Medical Center
• Other Medicare discharges
– Admitted through ER (non‐elective)
– Discharged with home health care
• ALOS (trimmed, untrimmed) = 2 days lower
• Contribution margin favorable
KeyВ StrategicВ BusinessВ Issues
• Know your audience (s)
• Speak their language
– Throughput, opportunity cost, contribution margin
•
•
•
•
•
UseВ theirВ data
MeetВ theirВ needs
Medicare admissions: less attractive post‐BBA
MedicareВ costВ reductionВ stillВ valuable
RiskВ contracts?
MountВ SinaiВ VisitingВ Doctors
VisitingВ Docs:В History
• Started in 1995 by three medical residents
• Primary and palliative care services for homebound • Second program at Mount Sinai Dept of Geriatrics merged with Visiting Doctors in 1997
VisitingВ Docs:В В Mission
• To provide a full spectrum of medical and psychosocial services to the homebound
• To alleviate caregiver burden
• To reduce unnecessary emergency room visits and hospitalizations
• To educate and train medical trainees and other healthcare professional students in the field of home care
VisitingВ Docs:
• Staffing:
–
–
–
–
–
–
–
12В homeВ visitВ physiciansВ 2В nurseВ practitionerВ inpatientВ careВ coordinators
3В socialВ workers
2 office‐based RNs
6В officeВ andВ administrativeВ assistants
SpanishВ interpreter
DataВ analyst/В researchВ coordinator
• Patients: Active census ~800 pts, > 1000 annually
ReferralsВ comeВ fromВ manyВ sources:
• Mount Sinai inpatient units (medicine, geriatrics, palliative care)
• Medicine and geriatric clinics
• City and community social service agencies
• Community nurses
• Family members
• Long term care facilities
Eligibility
• North of 50th street in Manhattan
• Chronically Home bound by medicare rules
• Must agree to change primary care physicians to our program
• Over 18 years old
UrgentВ Visits
• Telephone triage by RNs during day
• 24‐hour MD availability by telephone
• One provider on Urgent visits only for the week • Medical residents accompanied by students do UV 1‐2 times per week
• Geriatrics fellows accompanied by students do UV 1 time per week
Travel
• Taxi
• Walking
HomeВ VisitВ Safety
PreparedВ forВ allВ typesВ ofВ situations
CarryВ cellВ phones
OfficeВ knowsВ ourВ schedule
VisitsВ inВ AM
TravelВ inВ pairsВ (attendingВ andВ trainee)В orВ escort
• Never take stairs in public housing
• Pets in separate room
•
•
•
•
•
Technology
•
•
•
•
Labs:В orderedВ out
Xrays:В orderedВ out
EKG’s: our own “portable” machine
WirelessВ EMRВ viaВ hospitalВ systemВ (2007)
HomeВ CareВ Case
Ms. D is an 85 yo widow with DM, OA of knees and hips, and mild dementia who has fallen multiple times and is now missing most of her outpatient appointments because she is afraid of walking outside. She uses a cane and lives alone on the 3rd floor of a walk‐up building.  She has not left her apartment in 4 months, except when with her daughter to go to MD apts and church services about once a month.  At her last doctor’s appointment, you learn that her daughter now does her shopping and laundry, and is becoming overwhelmed because she also works full‐time and is raising a family. What is Home Care?
• Any diagnostic, therapeutic, or social support service provided in the home
• Includes
– Home medical care by a MD, NP or PA – Skilled nursing
– PT, OT, Speech therapy
– Social work
– Home health services
– Hospice
– Telemedicine
WhatВ isВ HomeВ Care?
• Professional
Nurse
Dentist
Podiatrist
PT/В OT/В speechВ therapist
Psychologist
Dietitian
Optometry
Pharmacist
• Diagnostic
Labs
Xray/Ultrasound
ECG/Holter monitoring
• Supportive
HomeВ HealthВ Aides
HomeВ Attendants
Homemakers
Home‐delivered meals
• Equipment
InfusionВ therapy
Ventilators
MedicalВ AlertВ Devices
Beds
Wheelchairs
Commodes
Lifts
JAMA,В 2003,В 290(9)
IsВ Mrs.В DВ Homebound?
MedicareВ HomeboundВ Rule
• “Normal inability to leave home”
• “Leaving home requires a considerable and taxing effort by the individual”
– Wheelchair, cane, assistance of another person
– Medical or psychological condition
• Can take trips outside home of “infrequent or of relatively short duration”
• Exceptions: healthcare, adult day care, religious services
CaseВ Continued
OnВ furtherВ reviewВ ofВ herВ medicationsВ inВ yourВ office,В youВ findВ multipleВ duplicateВ bottles,В someВ expired.В В Ms.В DВ isВ unableВ toВ rememberВ herВ medications,В andВ cannotВ demonstrateВ howВ toВ checkВ herВ fingersticks onВ herВ ownВ glucometer.В В HerВ bloodВ pressureВ isВ 150/85В (whichВ isВ new)В andВ herВ fingerstick inВ theВ officeВ isВ 250.В В HerВ gaitВ isВ unstableВ andВ shuffling,В ROMВ limitedВ byВ painВ inВ herВ knees,В andВ youВ feelВ herВ caneВ isВ noВ longerВ anВ appropriateВ assistiveВ device.
CanВ youВ referВ Ms.В DВ toВ aВ nursingВ agency?
WhoВ qualifiesВ forВ homeВ care?
• “Skilled Need”
• Don’t have to be permanently homebound to get home care services
• Don’t have to be elderly to get home care services
Medicare: “Skilled”Home Care
• A physician can refer any patient with an acute skilled need to a home care agency:
• Nursing care –
–
–
–
MonitoringВ ofВ vitalВ signs,В cardiovascularВ status
MedicationВ titration
WoundВ care
MonitoringВ ofВ symptomsВ (sob,В n/v,В painВ etc.)
• Physical therapy
• Speech therapy
• Infusion therapy
Examples
RNВ referral:
• Monitoring VS – BP, HR, temp, post‐op drains
• Titrating medications for symptom management
– pain, shortness of breath, side effects
• Wound care – post‐op, decubiti
• Family and patient education regarding diabetic/ CHF monitoring and management; trach
suctioning,В tubeВ feeds,В peg/ostomy care
Examples
PTВ referral:
• Gait and balance training
• Home and safety assessment
• Family/caregiver education re: ROM exercises
• Evaluating and teaching assistive devices (e.g. walker, wheelchair, Hoyer lift)
OtherВ factorsВ toВ consider:
FunctionalВ impairment
ProgressiveВ cognitiveВ decline
RecurrentВ admissions
FrequentВ falls
OverwhelmedВ familyВ members
. . . What’s going on?
NeedВ toВ understandВ homeВ environment
MakingВ aВ Referral
• Phone / Fax – specialized forms
• May want to check with HMO re: preference for agency, etc.
• Key points:
– Be specific
– Include parameters
– Include how and when to contact you
OnВ initialВ contactВ withВ homeВ careВ nurse:
•
•
•
•
•
•
IdentifyВ primaryВ nurse/therapist
Obtain/verifyВ contactВ information
ClarifyВ goalsВ ofВ treatmentВ plan
AskВ forВ input
EncourageВ openВ communication
UpdateВ nurseВ whenВ youВ makeВ changes
CaseВ Continued
You order home nursing and PT services.  Nursing is able to teach Ms. D how to check her fingersticks and you are pleased that with prepouring of her medications by her daughter (taught by RN), her fingersticks have improved to 100‐120s and her knee pain is improved with standing acetaminophen.  Her blood pressure remains elevated on repeat checks by the RN, and you start an antihypertensive and order follow‐up labs to be checked at home to monitor her electrolytes.  The labs return normal, and you continue the current dose of BP pill.  The physical therapist performed a home safety eval and has assisted the daughter in securing loose rugs, removing clutter, and has contacted you to order a new rolling walker, bath seat with grab bar, and raised toilet seat.  In the last month, you spend over one hour discussing the plans of care with the nurse and therapist.
HowВ doВ youВ orderВ labs?
OnceВ skilledВ serviceВ hasВ beenВ establishedВ otherВ servicesВ mayВ alsoВ beВ availableВ fromВ theВ skilledВ nursingВ agency:
•
•
•
•
•
In‐home laboratory testing
SocialВ work
HomeВ healthВ aideВ services
OccupationalВ therapy
Nutritionist
HowВ doВ youВ orderВ herВ walker?
MedicalВ Equipment
•
•
•
•
•
Durable
HospitalВ Bed
Wheelchair
Walker
Commode
Lifts
•
•
•
•
•
Non‐durable
Chux
Diapers
Wipes
Gloves
Dressings
OrderingВ Equipment
• Most can be done by phone call followed by signing papers by mail or FAX
• Vendor will need patient’s diagnosis, location, phone number, insurance info
• Few items require a written prescription
HomeВ MedicalВ EquipmentВ (HME)В Orders
• 11 standard Medicare forms “CMN’s” (Certificates of Medical Necessity) cover all durable medical equipment and oxygen
• Series of Y/N questions
• Some may require supporting documentation
HomeВ MedicalВ Equipment:В Caveats
• Never back‐date a form
• Never accept an equipment company’s oxygen saturation reading
• Never sign for equipment that you do not believe is medically necessary
CanВ youВ getВ reimbursedВ forВ coordinatingВ thisВ care?
HomeВ CareВ Certification
•
•
•
•
•
•
NewВ inВ 2000
Rationale:В EncourageВ participationВ inВ homeВ care
WhenВ youВ orderВ homeВ careВ servicesВ youВ willВ receiveВ aВ certificationВ formВ (aka 485)
Review,В sign,В andВ returnВ toВ agency
DocumentВ involvementВ inВ chartВ (seeВ handout)
SubmitВ billВ toВ MedicareВ (G0180В $90;В G0179В $70)
CareВ PlanВ Oversight
• Medicare pays for oversight of patients receiving acute skilled home care or hospice care
• >30 minutes per month in billable activities
• Examples: speaking with home care RN, PT, medical decision making, reviewing consultant reports or lab work
• Document activities and time spent in chart
• Submit bill to Medicare. Include agency number
• G0181$140; G0182 $150
After 8 weeks, nursing and PT express improvement in Ms. D’s functional status at home and have signed off the case due to the lack of skilled needs.  However, she is still unable to get to your office without her daughter’s help because of her reliance on her walker and difficulty getting down the stairs of her walk‐up.  She missed an appointment with you last week because her daughter had to work, so you decide to do a home visit to follow up her diabetes, new dx of hypertension, and pain control.
HomeВ Visits
• Can be done by MD, NP, PA
• Must document medical necessity for every home visit
• Patients who require ongoing home visits must meet the Medicare Homebound Rule
HomeВ Visits
• If you do them, bill!
• 5 codes for new visits; 4 for revisits
• Another set for assisted living/adult homes (domiciliary)
2008 Fee Schedule for Housecalls
Type of
HomeVisit
CPT code
Face-to-face time
(min)
2008 Medicare
Allowable ($) (6
month adjusted)
NEW PATIENT
Problem focused
99341
20
47.32 (52.29)
Expanded problem
focused
99342
30
69.08 (76.34)
Detailed
99343
50
109.24 (120.72)
Comprehensive
99344
60
142.90 (157.92)
Comprehensive
99345
90
172.03 (190.10)
Problem focused
99347
15
45.31 (50.07)
Expanded problem
focused
99348
30
68.24 (75.41)
Detailed
99349
40
99.50 (109.95)
Comprehensive
99350
72.5
139.22 (153.85)
ESTABLISHED
PATIENT
What can you bring with you in your “black bag”
WhatВ weВ bringВ onВ visits
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•
•
•
•
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•
BagВ (rolling,В backpack,В overВ theВ shoulderВ bag)
Stethoscope
Ophthalmoscope,В otoscope
BPВ cuffВ (variousВ sizes)
PulseВ oximeter
Thermometers
Gloves
Hemocult cards,В developer,В lubricant
WhatВ weВ bringВ onВ visits
•
•
•
•
•
•
•
•
TongueВ depressors,В swabs
BloodВ drawingВ materials
SpecimenВ cups
SimpleВ dressingВ materialsВ (gauzeВ andВ tape)
EarВ curettes
SharpsВ container
InstantВ handВ sanitizer
SoapВ andВ paperВ towels
OtherВ possibilitiesВ atВ home
Arthrocentesis
EKGВ machine
Home x‐ray services
HomeВ bloodВ drawingВ services
• i‐STAT machine
• Toe nail clippers
•
•
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PatientВ suppliedВ materials
•
•
•
•
Scales
Glucometers
DressingВ materials
PeakВ flowВ meter
When you see Ms. D after your office hours, she is disheveled and her clothing smells of urine, but much safer with her walker and her BP and fingersticks are better‐controlled.  She has left the milk out on the counter and the refrigerator open, and has not finished the breakfast prepared for her by her daughter earlier that day.
CanВ youВ getВ someoneВ toВ helpВ herВ atВ home?
HomeВ HealthВ Aide/
HomeВ Attendant
HOMEВ HEALTHВ AIDE
• Medicare funded
• Short duration
• Pt. must have concurrent
acuteВ skilledВ care
• A few hours per day
HOMEВ ATTENDANT
• Medicaid funded
• Chronic duration
• No need for concurrent acute skilled care
• Up to 24 hours per day (in New York)
ResponsibilitiesВ (Both)
• ADL support (bathe, feed, toilet, dress)
• Cannot administer meds (even pills)
– Can “remind” or “supervise”
• Cannot give tube feedings
• Cannot do wound care
Because Ms. D does not qualify for state‐funded home care, you recommend that her daughter hire an aide to supervise Ms. D during the day.  She agrees that this is necessary, and hires an aide to stay with Ms. D for 10 hours/day to remind her to take her meds, accompany her to MD appts, do food shopping, laundry and assist in her personal care and hygiene.  Ms. D’s daughter’s caregiver stress is relieved as she now only has to visit her mom after work and on weekends to prepour her meds and can focus on spending more quality time with her during her visits.
BU Trainees on Home Visits
Serena Chao MD MSc
Boston University Medical Center
Students
• Geriatrics and Home Medical Care
Rotation
• Required one month rotation: 4th year
• Home visits are the major component
Students
• 2 home visit sessions
per week
• Supervised by MD, NP,
or advanced practice
nurse (APN)
• 1-2 students per
preceptor
• Routine follow-up
• 5-7 patients
Students
•
Interview 2-3 patients (supervised)
– Review charts prior to visit
– Perform focused history and physical
– Generate assessment and management
plan
•
Independent home visit (end of month)
Internal Medicine Residents
• One-month Geriatrics Ambulatory block
– 2 residents per month
– 2nd or 3rd year residents
– 2 home visit sessions per week,
supervised by MD or APN
– Routine follow-up
– One session = 3-7 patients
Internal Medicine Residents
• Primary care track residents (n=15):
second clinic starting in 2nd year
– One option: longitudinal home care panel
– Follow 10-12 patients, supervised by
MD/APN/NP team
– Independent home visits one day a week
during ambulatory/elective months (4 mo)
– See each patient 2-3 times within a year
Internal Medicine Residents
• Primary care track interns (n=5):
Geriatrics Ambulatory experience
– 2 weeks: introduction to systems of care in
geriatrics
– At least one home visit with attending MD
and APN
– At least one home visit with visiting nurse
and/or PT from a community VNA
Geriatric Medicine Fellows
• Longitudinal home care panel
• Collaborative care model: attending MD,
APN, NP
• Function as PCP for 20-25 patients
• Independent routine follow-up visits one
half day per week
• See each patient every 2 months
Trainee Safety
• Detailed Home Care Security Policy
• Students never go alone
• Trainees must tell someone else they
are making house calls
• All must carry cell phones
• If trainees feel uncomfortable, they
should leave
JohnsВ Hopkins
ElderВ HouseВ CallВ Program
JenniferВ Hayashi,В MD
JohnsВ HopkinsВ ElderВ HouseВ CallВ Program
• Learners
– Medical students
• Basic medicine clerkship
• Summer scholars
• Geriatrics elective
– MPH students
– Internal medicine residents (3 programs)
– Fellows
– Physician observers
JohnsВ Hopkins
ElderВ HouseВ CallВ Program
• Learner integration
– Graded responsibility
• ObservingÆdoingÆteaching
• Varies with duration/intensity of exposure
– Clerkship students go out with preceptor (4:1) for 1‐2 visits on one afternoon; fellows run the clinical service, including team meetings, and precept residents and students
• Safety: pay attention, trust your instincts VCU House Calls Program
PeterВ A.В Boling,В MD
ProfessorВ ofВ Medicine
VirginiaВ CommonwealthВ University
Education
• High volume, low intensity
– Exposure to concept
• Mandatory for all 190 M2’s in groups of 2
– One afternoon per group
– Defined learning objectives
• Mandatory for all medicine interns
– Few afternoons
• Reinforced in clinical rotations via encounters
• Electives
MountВ SinaiВ VisitingВ Doctors
Trainees
• 140 medical students, required in 3rd year 1 week
• Medicine R2’s 1 month rotation
• Med‐Peds R4’s 2 week rotation
• Geriatrics and Pall care fellows (1 month + longitudinal experience)
• Elective trainee: visiting geri fellows, psych interns, elective students, 4 year students
Curriculum
• 3rd year students: 1 hour talk on role of SW
• Medicine R2: – 4 sessions on palliative care
– 4 sessions on literature and medicine
– Home care financing
– Geriatric health screening
Safety
• Residents and Students never do solo visits
• Geri fellows can do solo visits when to a continuity patient they know
• We keep list of their cell phones and know which patients they are seeing
LiteratureВ ReviewВ ofВ TeachingВ HomeВ care
JenniferВ Hayashi,В MD
EvidenceВ Base
• Home visits affect attitudes
• Home visits develop clinical competencies
• No single “best practice”
MedicalВ StudentВ Data
• Attitudes
– Improved attitudes toward house calls after rotation (p<0.03)
• Integration of psychosocial and medical issues
• Caregiver support, family dynamics
• Comprehensive view of patient
– More likely to include house calls in future practice
PageВ 1988
(MedicalВ StudentВ Data)
• Factors that influence attitudes
– Contact with physician program director
– Number of visits
– Physician‐precepted visits
– Negative predictor:  number of didactic hours
FlahertyВ 2002
(MedicalВ StudentВ Data)
• Competencies
– Medical knowledge
• Functional assessment
• Geriatric syndromes
• Progression of chronic disease
– Interpersonal/communication skills
• Affirming the humanity of medicine
• Understanding patient beliefs
• Understanding family systems
Medina‐Walpole 2005
(MedicalВ StudentВ Data)
• Competencies
– Medical knowledge/patient care
• Chronic illness care
• Patient goals/preferences
– Practice‐based learning (reflection)
• Attitudes toward geriatrics, chronic illness
• Applications in training and practice
• Creative project
YuenВ 2006
(MedicalВ StudentВ Data)
• Competencies
– Systems‐based practice
• Discharge planning needs
• Caregiver/family roles
– Interpersonal/communication skills
• Doctor‐patient interaction (“power dynamic shift,”
empathyВ andВ patienceВ inВ homeВ setting)
• Importance of building rapport
YuenВ 2006
(MedicalВ StudentВ Data)
• Competencies
– Interpersonal/communication skills
•
•
•
•
InterdisciplinaryВ teamВ approach
SkillsВ development
AppreciationВ ofВ contributionsВ ofВ otherВ disciplines
“Debunking” of stereotypes and misconceptions of other disciplines
WheelerВ 2007
ResidentВ Data
• Knight 1991 (Family Medicine)
– Making house calls during residency and having faculty who make house calls predict graduates’
practice
• Perkel 1994 (Family Medicine)
– Generally positive attitudes about home visit experience, sustained over time
(ResidentВ Data)
• Stoltz 2001
– Fewer than half of internal medicine residencies have any lecture on home care in their curricula
– 25% require any kind of home visit experience
– About 1/3 have no instruction in home care
(ResidentВ Data)
• Matter 2003
– Emphasis on transition from hospital to home
– Visits, conversations with families, and guided small‐group presentations “have altered the manner in which they plan to care for older patients in the future.”
• Increased awareness of communication deficits and barriers; discharge planning
• Importance of working in teams
• Adaptive functioning and resiliency at home
ProgramВ Structure
• Medical students
– Precepted visits (Page 1988, Flaherty 2002, Yuen 2006)
– Interdisciplinary student visits (Wheeler 2007)
– Healthy volunteer interviews (Thom 1995)
– Longitudinal visits (Eleazer 2006)
ProgramВ Structure
• Residents
– Precepted visits during “block” (Champney 1994, Smith 2006)
– Collaboration with APS (Jogerst 1997)
– Professionalism curriculum (Coller 2002)
– “Hospital‐to‐Home” transition (Matter 2003)
– Longitudinal primary care (Hayashi 2007)
Take‐Home
• Home visits affect attitudes at all levels of training
• Home visits develop clinical competencies at all levels of training
• No single “best practice”
• No outcomes data
– Learners
– Patients
– Costs
References
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Page AE, Walker‐Bartnick L, Taler GA et al.  A program to teach house calls for the elderly to fourth‐year medical students.  Jour Med Ed 1988; 63:51‐58.
Flaherty JH, Fabacher DA, Miller R et al.  The determinants of attitudinal change among medical students participating in home care training: a multicenter study. Acad Med 2002; 77:336–343.
Medina‐Walpole A, Heppard B, Clark NS et al.  Mi casa o su casa?  Assessing function and values in the home. J Am Geriatr
Soc 2005; 53:336–342. Yuen JK, Breckman R, Adelman RD et al.  Reflections of medical students on visiting chronically ill older patients in the home. J Am Geriatr Soc 2006; 54:1778–1783.
Knight AL, Adelman AM, Sobal J.  The house call in residency training and its relationship to future practice. Fam Med 1991; 23:57‐59.
Perkel RL, Kairys MZ, Diamond JJ et al.  Eleven years of house calls: a description of a family practice residency program’s experience from 1981‐1992 with and urban home visit program for the elderly.  J Long Term Home Health Care 1994; 13:13‐
26.
Stoltz CM, Smith LG, Boal JH.  Home Care Training in Internal Medicine Residencies: A National Survey.  Acad Med 2001; 76:181–183.
ThomВ D,В Yeo G,В LeBaron S.В В StructuredВ studentВ interviewsВ ofВ eldersВ atВ homeВ duringВ aВ familyВ practiceВ clerkship.В В Acad MedВ 1995;В 70:446.
Eleazer GP, Wieland D, Roberts E et al.  Preparing medical students to care for older adults: the impact of a senior mentor program. Acad Med 2006; 81:393–398.
Champney KJ.  The physician’s role in Boston University’s Home Medical Service.  Caring 1994; 13:48‐51. Smith KL, Ornstein K, Soriano T.  A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward. J Am Geriatr Soc 2006; 54:1283–1289.
Jogerst GJ, Ely JW.  Home visit program for teaching elder abuse evaluations.  Fam Med 1997; 29:634‐639.
Hayashi JL, Phillips KA, Arbaje A et al.  A curriculum to teach internal medicine residents to perform house calls for older adults. J Am Geriatr Soc 2007; 55:1287–1294.
TeachingВ Case
CaseВ Study:В N.V.
• 79 year‐old woman with stage 4 breast cancer with diffuse metastases.
• Severe pain from bone involvement.
• On 14 prescription medications, including opiates.
• Unable to walk and alternates time between bed and chair.
N.V.:В SocialВ History
• Widowed twice.
• Step‐daughter from second marriage is patient’s health care proxy and is involved in her care.
• Patient lives with home attendant.
• Has Medicare and Medicaid.
N.V:В GoalsВ ofВ Care
• Remain at home
• Pain control
• Enjoy life as much as possible
N.V.:В HomeВ Care
• Home attendant 24 hours a day
• Visiting nurse for prepouring meds and to monitor patient status
• Has hospital bed, patient lift, wheelchair
• Intermittent physical therapy
WhatВ topicsВ canВ beВ taughtВ onВ aВ homeВ visitВ toВ N.V.?
MedicalВ Knowledge
HomeВ careВ patientsВ exhibitВ aВ wideВ varietyВ ofВ chronicВ medicalВ conditionsВ commonВ toВ adultВ &В geriatricВ populations
MedicalВ Knowledge:В CaseВ ofВ N.V.
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•
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•
•
•
DM
PainВ management
HomeВ safety
Falls
PressureВ sores/ulcers
GoalsВ ofВ care
PatientВ Care
• Home visits: an opportunity to teach students the importance of incorporating environmental and social factors in patient care plans
– Matter et al. Acad.Med. 2003; 78:793‐797
– Yuen et al. JAGS 2006; 54:1778‐1783
– Hayashi et al. JAGS 2007; 55:1287‐1294
• Teaching point: tailor care to the patient as an individual
PatientВ Care:
FunctionalВ Assessments
• Utilize functional assessment tools as appropriate
– Matter et al. Acad.Med. 2003; 78:793‐797
– Hayashi et al. JAGS 2007; 55:1287‐1294
• Refer patient for community services as appropriate, based on functional needs
PatientВ Care:В HomeВ Safety
• Assess home environment for safety risks
–
–
–
Matter et al. Acad.Med. 2003; 78:793‐797
Medina‐Walpole et al. JAGS 2005; 53:336‐342
Yuen et al. JAGS 2006; 54:1778‐1783
• If falls and/or safety risks are identified, recommend appropriate measures to improve patient’s safety
• Refer to home safety evaluation by home PT as appropriate
PatientВ Care:В DrugВ Management
• Perform medication reconciliation—is the patient taking what you think he/she is taking?
• Recognize polypharmacy vs. inappropriate prescribing
• If medication noncompliance is present, recommend measures to increase compliance
– Matter et al. Acad.Med. 2003; 78:793‐797
– Medina‐Walpole et al. JAGS 2005; 53:336‐342
PatientВ Care:В DurableВ MedicalВ Equipment
• Show students DME in patient’s home
–
Matter et al. Acad.Med. 2003; 78:793‐797
• DME is covered by Medicare Part B
– Requires a copayment
– Includes hospital beds, walkers, home oxygen
PatientВ Care:В WoundВ Care
• Routinely assess skin of patients with decreased mobility
• Be familiar with different kinds of wounds and their treatments (pressure ulcers, venous stasis ulcers, arterial ulcers)
• Communicate with visiting nurses who provide wound care management
Systems‐Based Practice
“Demonstrate an awareness of and responsiveness to the larger context and system of health care…”
– http://www.acgme.org/outcome/comp/compFull.asp
• Describe the role of visiting nurses, home health aides/personal care attendants, home PT/OT/ST
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–
–
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Matter et al. Acad.Med. 2003; 78:793‐797 Medina‐Walpole et al. JAGS 2005; 53:336‐342
Yuen et al. JAGS 2006; 54:1778‐1783
Hayashi et al. JAGS 2007; 55:1287‐1294
“ . . . observing interaction of patient and aide
at home. . .”
HomeВ CareВ Systems
Pharmacists
Physical
Therapists
Home Attendants
Nurses
Patient
Medical
Equipment
Companies
Physicians
Family
Occupational
Therapists
Social Workers
Practice‐Based Learning
• Evidence‐based medical care can be provided in the home, but it may be challenging
• Learners can reflect how care differs in home setting compared to traditional outpatient or inpatient settings
“Being able to visualize the different types of
places people live. . .”
“Better understanding of old people’s .
. . difficulties in getting healthcare . . .”
InterpersonalВ andВ CommunicationВ Skills
• Being in a patient’s home necessitates a different kind of interaction
• Learn to communicate with caregivers
• Effective communication with members of the multidisciplinary care team is crucial
– Yuen et al. JAGS 2006; 54:1778‐1783
“. . . to see patients more as people in their
home environment . . .”
Professionalism
• Chance to observe trainees and have trainees observe you
• Dealing with ambiguous situations
• Demonstrate how personal knowledge of the patient influences the decisions made
– R. Epstein JAMA 1999;282:833‐839
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