A Home Care Practice That Works

Dr. Ted Rosenberg

Dr. Jay Slater

Objectives

• Outline 2 models of home care practices– Funding– Staffing

• Describe patient populations

• Review “goals”

• Discuss services and interventions (“A day in the life”)

Objectives

• Illustrative cases

• Discuss relevance of clinical practice guidelines

• Measuring outcomes

Home ViVE Program

• “Home Visits to Vancouver’s Elders”

The Office

The Office Assistant

The Office Manager

The Mandate

• Providing comprehensive care to frail elderly patients in their homes

• Keeping our patients out of hospital as much as possible

• Keeping our patients in their homes and out of care facilities as much as possible

The Team

• Hester Chan – Part-time MOA

• Gisela Jaschke – RN, Case Manager

• Drs. Rod Ma, Conrad Rusnak and Jay Slater – all doing half-time home care practices

The Extended Team

• Home Care Nurses

• Home Care Physio and OT

• Case Managers

• Geriatric Triage Nurses (ER)

The Virtual Team

• Mobile Lab

• Mobile Podiatry, Optometry

• Palliative Care, Mental Health teams

• Geriatric Day/In-Patient Programs

• Etcetera…

Model #1

• Publicly-funded– Fee for Service

• Supported with “Community” funds (office space, support staff, RN)

The Practice

• 124 patients at intake

• 32 lost to death or long-term care– 20 deaths (all but 3 died out of hospital)

• 5 found other care

• 30 new patients to practice

• 117 patients at present

The Practice

• Demographic– Really Old (85 years)– Really Complex

• “Patients who are unable on a consistent basis to get out for medical care and/or whose current Family Physician can’t consistently provide home visits”

Referrals to Program

• Case Managers, Home Care Nurse

• ER Personnel

• Hospitalists, Case Managers

• Geriatric Programs

• Mental Health, Palliative Care teams

The Practice

38

18 1719

11

27

20

42

0

5

10

15

20

25

30

35

40

45

1

type of disease

# o

f p

ati

en

ts

HTN

CHF

CAD

CVD

DM

CKD

COPD

Dementia

The Practice

Total patients: 114

29 29

2220

11

3

0

5

10

15

20

25

30

35

1

# ratio of disease

# o

f pat

ien

ts no chronic disease

1 chronic disease

2 chronic diseases

3 chronic diseases

4 chronic diseases

5 chronic diseases

The Practice

• The group with “No Chronic Disease” include frail, house-bound patients with:– Advanced Parkinson’s– Advanced MS– CMT– Advanced Cancer– Advanced AIDS– Severe Arthritis

Challenges

• Defining Goals

• Assessing Frailty– MSC has put “patient convenience” into the

exclusion for billing a house call

• Appropriate use of Clinical Guidelines

• Technology (mobile EMR)

• “Right-sizing” the practice

Evidence-based clinical practice guidelines (CPGs) are increasingly popular as tools for improving quality of care, but Dr Cynthia M Boyd (Center on Aging and Health, Johns Hopkins Medical Institutions, Baltimore, MD) argues that they provide poor guidance for the care of the older patient with multiple comorbid diseases. This has major implications for clinicians treating older patients, since adherence to such guidelines is often used as the basis for pay-for-performance reimbursement decisions.

Adhering to CPGs for one chronic condition may cause other problems or exaccerbate other existing diseases.

August 10, 2005 issue of the Journal of the American Medical Association.

Case #1 –Mrs. N. E.

• 97 y widow

• Other than blindness no significant medical history. Visits “prn”

• Stoic – “Few weeks of weakness and swelling in the feet”

• Rapid A. Fib, Crackles and edema to knees = CHF

Case #1

• Diuresed with Lasix

• Rate reduced with Metoprolol then controlled with Digoxin

• Warfarin started for CVA prophylaxis

• RN / Case Mgr able to monitor weight and clinical status, and offer home support

Case #1

• Symptoms improved over weeks

• Patient then revealed a skin wound on her L shin that she’d been treating herself

• RN’s visit for dressings, antibiotics for associated cellulitis - resolved

• Regular follow up visits to monitor symptoms, clinical exam and weight

Outcomes

• 38% of patients visited ER at least once in the 27 months prior to ViVE

• 12% of patients visited ER at least once after ViVE

• Of those previously visiting ER, 31% have had no further ER visits since ViVE

Home-ViVE patients who visited the ED 27 months prior to program admission:Number of visits

One Visit50%

Two visits30%

Three visits6%

Four visits6%

Five visits6%

Seven visits2%

Number of ED visits per person/Patients visiting ED after Home-ViVE admssion

Two ED visits after Home-ViVE admission

81%

One ED visit after Home-ViVE admission

19%

The secret weapon

The Co-Secret Weapon Over 50

Victoria Practice Profile

• N= 328– Live in homes = 260 (80%)– Nursing Home = 68 (20%)

• Functional Status and Risk- Average:– Age 87.9– Tug 21. (n<10sec) - couldn’t cross street /#

risk– Berg Balance Scale- 38.1- risk of fall and # -

but in range for rehab and conditioning• 30-40% die at home in own beds

Victoria Practice Profile

• Problems n= 328– Dementia- 100– Chronic Pain (on narcotic)- 72– CHF -57 – O2- 13– Parkinson’s on treatment-25– Anticoagulated – 53– Complex medical conditions: Rheum, Neurodegen eg

ALS Parkinson +, ,pulm HTN/Fibrosis, Heme, onc, ID

Victoria Team

• Team– Direct Members

• 1 MD• 1.6 RN/gerontological nurses –directors of care (Vikki Hay, Anne

Adams)• 0.6 Physiotherapy/kinesiology (Carey Adams)• MOA (Liza Zacharias)• Patients, caregivers and families

– Indirect Members• SLP- community – swallowing• Lab• Pharmacists• Case Managers• Community HC teams, Hospice etc

Team

• Nursing services– Functional Assessments, MMSE, GDS etc– CDM chronic disease management– Monitor impact of drug changes- eg start ACHEI,

sinemet etc– Bowel and Bladder Care/education – eg catheters

and enema/disimpaction– Time consuming Procedures-Syringing ears, Ulcer

Dressing Unas Boots– Injections (eg monthly depomedrol, iron)

Immunization– Acute Care

Physiotherapy Pilot 3 phases

• Phase 1 – Jan- March . 2009 • Assess treatment needs and resources for people• Compile standardized profile of individuals and

group (eg berg balance, TUG etc)• Test assessment forms and work flow

• Phase 2 April –June– Consolidate procedures, evaluate individ service – plan roll out for Group exercise program.

• Phase 3 – Nursing Homes Survey - July - Aug– Assess needs of nursing home patients

CommunicationVirtual Team

• Electronic Record- Tablet PC• Meet in room for business- every 1-2 months• Meet everyday- multiple times

– Cell phone– Text Message

• Mrs. J. (Exac COPD). Coughing green sputum wheezing, b. basal crackles and edema temp 38.5 O2 saturation 93%,

• Allergy : emycin-vomit, penicillin• Pharm@250-386-7111 • I call in: prednisone,Moxi, Lasix• They see the next day

– Email- Team Report- progress notes from day and comment

Goals of Care

• In addition to reducing acute care and delaying LTC:– Enhance QOL

• Control Disabling symptoms• Maximize function

– Provide frail seniors with choice and control

Goals Families and Caregivers

• Reduce Caregiver Burden– Reduce work loss and time taking parent to doctor’s

office– Provide information about health status,

medications and treatment plan- they don’t feel they are working with one hand tied behind back and blind folded

– Prognosticate• Can stay home• Time look at alternative housing• Type of support

Can we reduce costs?

• Practice profile-outlier – investigations

• Costs vs Cost-effectiveness

99 year old male• Completely independent- history of multiple skin cancers• One “sprouted”- “lets wait”• 2 months

– Severe pain- allergy to acetoaminophen– Delirious with narcotics – Sleepless– Falling– 24 hour care-private/public 4 hours per day

• Referred for – daily radiotherapy for 14 days – Exhausting– Pain is gone and tumour is regressing– Cost to system v cost to family and patient

Costs of Care MSP –

2007 Profile• Me ($)/pteGP Median ($) Age/gender

Case Mix Adjusted $

• Medical- 653 102 1.22 (1.4) • Consult -392 72 0.65 (0.68)• Total MD- 0.88 (0.93)• Lab - 203 26 1.01 (.99)• Xray - 48 9 • Total - $ 1294 $208 Morbidity Ratio 1.37-1.57

Costs of Care -summary• Patients are higher morbidity even after adjusting age/gender

Summary- • After adjustment for age, gender and case-mix

– Physician Costs are less– Consults are less– Lab is the same

• Does not include Cost Savings– Emergency visits Saved (>$1000/visit)– Hospital Days Saved– Nursing home days

• Cost/Quality Adjusted Life year

Differences in Funding

• Public– Bill MSP for direct medical care – pays

salaries, equipment (eg Tablet PC’s support) and Overhead

• Private (Annual Practice fee or pay as you go)- services not covered by MSP– Team– Indirect Contact: phone, email, family

meetings Multitude of forms etc

Complex Team Primary CareCase Presentation

• End of Nov.2008 Call from Experienced HCN– “Help”– 91 year old lady living with husband in old

house in Oak Bay- failing in community– Home situation falling apart– Palliative Care?

Initial Assessment

• Severe Depression- GDS 5/5; refusing MMSE (subsequent 22/27)- “I want euthanasia”

• Cachectic• Severe Parkinsons

– Drooling– Wheelchair – 1 person assist transfers– Shuffle few steps– Falling– Severe tremor right hand

Initial Assessment

• Up hourly– Urine– Restless legs and dystonia, aching in thighs

• Severe Constipation – last BM 6 days ago-”told by Dr. to avoid laxitives”

• Deaf –impacted wax in ears• Visual Impairment AMD• Decubitus on Coccyx- horse shoe painful callus

Initial Assessment

• Neglect– Long Beard and Moustache– Hair Stringy– Blue/green mould in ear canal

• Cluttered House • Pills all over the place• Husband trouble staying awake and insisting on

managing pills• Paid CG at lunch cowering in kitchen• You can’t help us –leave us alone

Where Do You Begin?

• Can you do this in an office?

Careplan/interventions

• MD– Blister Pack meds-

• Husband took them out and put into dosette• Agreed to let paid caregiver review

– Imipramine –stopped the drooling and reduced nocturia to 1x/night

– Parkinson’s• Moved Requip to HS – end of RLS • Added rapid acting sinemet in a.m. to jump start in a.m• and spread out CR to 4 x day. 3 weeks later added comtan over 2

weeks– AM Care – went from 3 hours to 1 hour and up at 9:00– Tremor –better could use eating utensils– Independent to stand by with transfers and walking in house

Interventions

• Depression– Partial Improvement- added effexor– GDS 0- “changed my mind about euthanasia”

• NSg– Syringed ears- could communicate– Started Lactulose – BP – 180 – added felodipine– Chocolate ensure and diet– Baza cream for ulcer and education– Called Daughter- re: shave, hair and bath assist, increase HSW

• PT- Roho cushion, Equip change, resistance exercises

Summary

• 8 weeks- “building trust and going with their priorities”– 4 MD visits– 4 nursing Visits– 2 PT visits – Phone calls – 8 the first week and none the last 3 weeks

• Outcome– Depression resolved– No longer drooling– Waking up 1-2x at night to void – No pain from dystonia/rls – Independent with mobility and walker– ADL time in a.m reduced from 4 hour – 1 hour– Dtr and caregiver Thrilled- Pte happy –husband not so sure

Conclusion

• For Frail Elderly, Home Based care– Better assessment of individual, environment and

supports and complex needs– Improved access to care for people who could not get

out to a doctor’s office easily– Better Outcomes

• Frail Elderly – QOL, function, choices, • Caregivers- reduce emotional and economic strain (eg time

off work for appointments)• Health Care System – keep out of ER and delay Nursing

Home Placement and Direct costs after adjustment for age gender and case mix