VA Home Care for Complex Chronic Disease

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1 Interdisciplinary InnoVAtion: VA Home Care for Complex Chronic Disease Thomas Edes, MD, MS Director, Home & Community-Based Care Office of Geriatrics and Extended Care U.S. Dept. of Veterans Affairs (VA) October 18,

2 I have no relevant financial relationships with any commercial products and/or providers of commercial services discussed in this CME activity. I do not intend to discuss unapproved/ investigational use of a commercial product/device in my presentation 2

3 AAP 2009 NCE, Washington Convention Center, Washington DC Session title: Section on Home Care Program: Pediatric Health Care in a Reforming Health Care System Session number: H2075 Faculty name: Thomas Edes, MD, FACP Faculty institution: US Department of Veterans Affairs 3

4 VA Home Care for Complex Chronic Disease VA Home Based Primary Care overview HBPC Outcomes clinical and economic Beyond HBPC - Medical Foster Home Longitudinal care through the end of life Beyond VA Independence at Home

5 % Change in Population from 2000 Veterans 85 + US 85+ US 65+ US Total 5

6 Demographic Imperative Projections from 2000 to 2010 US pop age 85+ to increase 44% Vet pop age 85+ to nearly triple, up 190% Of all Americans over age 65, one-fourth are veterans We are ALL taking care of veterans VA facing challenges a decade earlier 6

7 Increasing Disability with Age Percentage with dependency in at least 1 Activity of Daily Living (ADL) [bathing, dressing, toileting, transfer and feeding] Age 65: 10% Age 75: 18% Age 85: 47% 7

8 Costs of Chronic Disease 68% of Medicare $ for 20% with 5+ chronic conditions 4+ chronic conditions: 99x risk of hospitalization for ambulatory-care sensitive chronic condition avoidable Jennifer Wolff et al, Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly, Arch Internal Med;162. Nov 11, % of health expenditures for chronic disease (CDC) In VA: 2% of enrolled Veterans account for 36% of the cost; and 9% account for 52% of the cost. 8

9 What is VA Home-Based Primary Care (HBPC)? Comprehensive, longitudinal primary care Delivered in the home By an Interdisciplinary team: Nurse, Physician, Social Worker, Rehabilitation Therapist Dietitian, Pharmacist, Psychologist Targets patients with complex, chronic, disabling disease When routine clinic-based care is not effective For those too sick to go to clinic 9

10 HBPC is NOT like Medicare (MC) Home Care Different target population Different process Different outcomes HBPC provides longitudinal comprehensive, interdisciplinary care to veterans with complex chronic disease 10

11 Characteristics of HBPC Population Too sick to go to clinic - Mean age 76.5 years; 96% male More than 8 hierarchical chronic conditions 47% dependent in 2 or more Activities of Daily Living (ADL) 47% married; 29% live alone; Caregivers: 32% limited ADL Mean duration in HBPC 315 days; 3.1 visits/mo Medicare home care: 65 days; Home Hospice: 61 (2004) 11

12 Disease Prevalence in HBPC Percent of patients Disease with disease Heart disease 72% Diabetes 48% Depression 44% Heart failure 35% Dementia 33% Substance abuse 29% Cancer 29% Anxiety/Personality Disorder 24% PTSD 21% Schizophrenia 20% 12

13 Mental Health Providers in HBPC 2007: Support mental health providers in HBPC MH provider in ALL 134 HBPC programs Adding more on basis of need Cognitive therapy, behavior management, coping, grief, pain, dynamics, adjustment 13

14 HBPC Interdisciplinary Team Program Director - Social Worker or Nurse Medical Director physician; primary care; oversight Nurse nurse practitioners, registered nurses Social worker family, finances, support Rehabilitation therapist Occupational or Physical Dietitian 80 to 90% warrant nutritional management Mental Health Provider - psychologist Pharmacist medication reviews, team meetings ALL attend weekly team meetings ALL develop and sign a unified care plan 14

15 Differences Between VA HBPC & Medicare Home Care VA Home Based Primary Care Targets complex chronic disease Comprehensive Primary Care Skilled care not required Strict homebound not required Accepts declining status Interdisciplinary team Longitudinal care Reduces hospital days Medicare Home Care Remediable conditions Specific problem-focused Requires skilled care Must be homebound Requires improvement One or Multidisciplinary Episodic, post-acute care No definitive impact Limited geography & intensity Anywhere; anytime 15

16 Total Health Care Cost Before vs During HBPC; Columbia MO VAMC, 1994 Health Care Cost Per Patient Per Year Cost before HPBC VERA Allocation 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:

17 17

18 HBPC Challenges within VA HBPC is too expensive Lack of access to mental health services Intensity of service limits Geographic limits Lack of access to medical records in home 18

19 2002 Utilization Before vs During HBPC All HBPC programs; n=11,334 Care days or visits per patient per year Hospital BDOC Nursing home BDOC Outpatient visits All home care visits Before HBPC During HBPC Change % P < % % % 19

20 Costs of Care Before vs During HBPC (per patient per year) Total Cost of VA Care Before HBPC During HBPC Change $38,168 $29,036* - 24% P < Hospital $18,868 $ % Nursing home $10,382 $ % Outpatient $6490 $ % All home care $2488 $13,588* + 460% 20

21 Different Outcomes Analysis of 1 mil MC home care patients, 3 mil home visits - no impact of MC home care on hospital days - no impact of MC home care on total cost of care Retrospective case-control national analysis - all VA HBPC patients FY02 (11,334 veterans), avg 177d - 63% reduction in hospital days - 87% reduction in nursing home days - Cost of longitudinal HBPC $8,706 per patient per year - Net 24% reduction in VA total cost of care HC Welch, NEJM 1996 T Edes, JAGS

22 HBPC Reduction in Hospital Utilization Quality Measure implemented Sept 2006 Measure: Percent reduction in number of inpatient admissions and number of inpatient days Compare VA hospital and nursing home utilization DURING HBPC, to 6 months BEFORE enrollment in HBPC 22

23 2007 Utilization Before vs During HBPC All HBPC programs; newly enrolled in 2007: n= 8,231 Care days per patient per year Hospital BDOC Nursing home BDOC Total Inpatient BDOC Before HBPC During HBPC Change % P < % P < % -P <

24 Drill Down to Patient Level Drill Down 24

25 VA Inpatient Days Before and During HBPC

26 HBPC Quality Outcomes Inpatient days: 78% reduction 30 day readmission rate: 23.8% decrease Caregiver assessment: 74% Medication reconciliation note: 71% Satisfaction: Very Good or Excellent 82.7%...the highest overall satisfaction rating from all (VA) patient surveys" 26

27 Veterans Served Daily in HBPC 2000 to 2009 Avg Daily Attendance 25,000 20,000 15,000 10,000 5,000 7,312 9, ,514 20, Q09

28 Pushing the Boundaries: HBPC Home Based Primary Care now in 134 VA Medical Centers, plus over 90 CBOCs. Expand geographic reach: CCHT, ORH Expand staff Mental Health providers Expand impact on caregivers Resources to Enhance Alzheimer s Caregivers Health Expand technology testing sensor tech Expand beyond VA - Indep at Home bill

29 Pushing Boundaries Rural Health Funding Received - $28 M HBPC Expansion via 25 Outpatient clinics HBPC Expansion with 14 Indian Health Service (IHS) sites and Reservations Partnership with Indian Health Services HBPC Staff to Mentor Tribal Staff Tribes Providing in-kind Space, IT, Staff Geriatrics & Extended Care and IHS to Convene Mentoring Conference Calls

30 Factors for success Interdisciplinary team Target those with recurrent hospitalization Comprehensive care Home care team provides primary care Longitudinal care (rather than episodic) Follow caseload limits (eg: 20 to 30/nurse) Clinical judgment drives visit frequency Technology support: EMR, telehealth 30

31 Mobile Electronic Documentation Problem: Home care staff cannot reliably access Electronic Medical Record (EMR) in the field; paper not acceptable Solution: Software to allow EMR access and entry without connection Status: Completing Class I software, field testing this month; national roll-out soon

32 HBPC Economics 1) Veterans Equitable Resource Allocation internal budget support 2) Reduced cost due to decrease in VA inpatient days 3) Reduced divert costs

33 HBPC Economics For HBPC facility with ADC of 100 HBPC cost: $1.29 mil per 100 Veterans / year Reduced cost from decrease in VA inpatient days $1,260 cost of VA inpatient bed day of care (BDOC) 3.4 BDOC avoided per calendar day 1240 total BDOC avoided for 100 veterans/yr $1.56 million avoided per 100 veterans/yr

34 HBPC Economics Reduced divert costs in HBPC VA mean diversion rate: 4.4 BDOC/d Mean days avoided : 3.4 BDOC/d Mean contracted hospital rate $2,067/day On average, can avoid (3.4)x($2067)x(365) = $2.6 mil per hospital per year

35 VA Hospice & Palliative Care Numbers of Veterans receiving care? 38% of VA hospitals no palliative care Half did not purchase any home hospice 27% did not refer to home hospice Policy conflicted with Medicare Hospice not in VA budget Poor relationships with community hospices

36 VA Hospice & Palliative Care (HPC) No reliable data Workload capture No communication network for HPC HPC Point of Contact at every VA 38% no inpatient HPC programs 11,000 died in VA facilities with no HPC programs Palliative care teams in every VA All Networks trained in HPC program development (AACT)

37 VA Progress in Palliative Care Low use of community hospice Many unaware of hospice benefits Hospice-Veteran Partnerships: State based; hospice handbook Half of VA facilities purchased no home hospice care 27% did not refer FY04 VA Budget for home hospice first in VA history National standards for home hospice purchase

38 VA Progress in Palliative Care Few trained in palliative care Unrecognized differences for combat veterans Low use in all settings Fellowships; EPEC and ELNEC; Web; AACT Acknowledge differences, improved approach to EOL care Hospice-Veteran Partnerships; Escalating use; Elevating expectations

39 VA Transformation in Care at the End of Life Workload capture in all settings Policy consistent with Medicare Strong Community Partnerships Education physicians, nurses, CNAs Palliative care teams in every VA hospital 47% received pall care consult VA-paid home hospice tripled in 3 years T Edes, S Shreve, D Casarett, JAGS 2007

40

41 Medical Foster Home When nursing home is the only option, another option Seriously injured veterans from Iraq the L O N G long-term care 41

42 A Tale of Two Social Workers Two social workers at Little Rock VA Problem: Veterans in HBPC decline, not safe to live alone, refuse NH Opposing ethical principles Unsafe at home, or force out of home? Solution find a willing caregiver, meet medical care needs through HBPC Pilot 2002 cautiously optimistic success 42

43 What is Medical Foster Home? When nursing home is the only option, another option Merges adult foster home with VA home care HBPC or Spinal Cord Injury Home Care Angel in community takes dependent veteran into their private home, as MFH caregiver MFH caregiver provides daily personal assistance and supervision VA HBPC provides comprehensive medical care and management; caregiver education VA MFH Coordinator provides oversight Veteran pays for MFH

44 Who is a Candidate for MFH? Veteran with Disabling chronic disease or terminal illness Needs assistance & supervision No adequate caregiver Unable to live independently due to functional, cognitive or psychiatric impairment Meets nursing home level of care Meets HBPC criteria needs interdisciplinary care 44

45 Finding a Caregiver Drive: Compassion + Devotion, not money Able and enthused for daily care 1. Long-term commitment 2. Patient will get worse, not better - Job will get harder, not easier 3. Accept unannounced visits Still interested? You ve found an angel 45

46 Veterans Choose MFH 20% (17% to 24%) are P1a Veterans - VA will pay 100% of their nursing home costs - Options: remain at home, VA-paid NH, MFH - They CHOOSE MFH at THEIR OWN EXPENSE Strong evidence: (a) Not able to safely remain at home; (b) Like the option of MFH 46

47 Economics of MFH Medical Foster Home Cost Avoidance MFH program operation cost per year* = $140,000 17% of Veterans in MFH are Priority 1a 3 P1a Veterans in nursing home or CLC = $540,000 MFH at 3 sites: 20 P1a Veterans in MFH Avg CNH or CLC = $171,185/yr 20 Veterans x $171,185 = $ 3.4 Mil per yr for 3 VAMCs Less $420k costs = $1 Mil saved per VAMC per year * Based on ADC of 35 MFH Veterans. Costs from FY08 MPCR.

48 Benefits of MFH VA offers an option to NH care, in a less restrictive environment - in a home MFH less costly than nursing home Benefits to caregivers Benefits to community 48

49 New Care Settings - MFH 2008: Two year funding for 32 sites 21 sites operational 2010: 2 yr funding for 25 added sites Office of Rural Health support 5 sites

50 Congressional Budget Office Report, Dec 2007 Increase in health care cost, VA costs/ patient: rose 1.7% (0.3% /yr) Medicare costs/ patient rose 29.4% (4.4% /yr) Highest cost: chronic disabling disease; homebound. Elements of VA healthcare system Electronic medical record Quality and performance measures Systems for chronic disabling disease: HBPC 50

51 Spreading HBPC Beyond VA What will it take? Challenges: 1. Economics incentive to avoid preventable hospital and nursing home 2. Balancing measure avoid restraint 3. Workforce - numbers and expertise 51

52 Spreading HBPC Beyond VA What will it take? 1. Financial structure to support home care: longitudinal, interdisciplinary, comprehensive 2. Incentives rather than punishment for taking on those with complex chronic disabling disease 3. Incentives to manage them well 4. Balancing measure avoid peril of blocking from desirable care 5. Access to records across settings 6. Workforce - numbers and expertise 52

53 Independence at Home Bill 1. Home care for complex chronic disabling disease 2. Financial structure 3. Longitudinal, comprehensive 4. Interdisciplinary, primary care provider 5. Measures for competency and quality 6. Accessible electronic records 7. Balancing measures 8. Incentives for workforce 53

54 Home Care for Chronic Disease 1. Need to expand non-institutional long term care what we want, where we want it, at lower cost 2. Effective models: HBPC, MFH 3. Address mental health in chronic disease 4. It s all about teams interdisciplinary teams coordinate care across all settings 54

55 5. Home care for chronic disease is not effective as an episodic inoculation. 6. Effective home care for chronic disease must be INTERDISCIPLINARY (not 1or2) LONGITUDINAL (not episodic) COMPREHENSIVE (not focused), and INTEGRATE primary care. 7. Complex chronic disease? Home Care is the answer! 55

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