Home Based Primary Care: An Interdisciplinary Model of Care in the Department of Veterans Affairs

Mandy McCorkindale, PsyDClinical Psychologist, Home Based Primary Care

Julie Ruple, PharmD, CGPClinical Pharmacist, Home Based Primary Care

Central Arkansas Veterans Healthcare System, Little Rock, Arkansas

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #E5aOctober 18, 2014

Faculty Disclosure

• We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the need for cost-effective, patient and family centered Home-Based Primary Care (HBPC) services for the geriatric population.  

• Describe an integrated, primary care model for in-home care involving team members from a wide range of disciplines.

• Discuss the roles of the psychologist and pharmacist in promoting a whole-person approach to the management of patients with complicated medical/mental health problems.

• Describe the application of an HBPC program in a rural area, including unique challenges to in-home care, barriers to effective implementation, as well as patient and team successes.

What is Home Based Primary Care?

“Home Based Primary Care is health care services provided to Veterans in their home. A VA physician supervises the health care team who provides the

services. Home Based Primary Care is for Veterans who have complex health care needs for whom routine

clinic-based care is not effective.”

U.S. Department of Veterans Affairshttp://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp#

Goals for HBPC Promoting health and independence

Reducing the need for hospitalization, nursing home care, ER visits, and outpatient clinic visits

Assisting by adapting the home for a safe and therapeutic environment, arranging supportive services, and providing patient and caregiver education

Supporting the caregiver in the care of the veteran

(Beales & Edes, 2009)

Goals for HBPC Meeting the changing needs of the veteran and family

Enhancing the veteran’s quality of life through symptom management and other comfort measures

Allowing the veteran the option of dying at home rather than in an institution

Helping the veteran & family cope with chronic disease

Providing an academic and clinical setting for training

(Beales & Edes, 2009)

Population Served

• Complex, chronic, disabling disease• Disease prevalence • Demographics / clinical characteristics• 47 percent of pts are dependent in 2 or more

ADLs• Routine, clinic based care is no longer effective• Inclusion criteria for CAVHS

(Edes, 2010)

Rationale for Cost

Cost Reduction Seen Through:  Results: 

fewer inpatient hospitalizations 56% reduction in hospital Bed Days of Care (BDOC)

decrease in readmission rates 78% reduction in inpatient days of care

decrease in nursing home placements 84% reduction in nursing home BDOC

overall reduction in combination of VA and Medicare utilization and costs

HBPC associated with a 25% reduction in hospital admissions, 36% reduction in hospital days, and 13% reduction in total VA plus Medicare costs after accounting for the cost of HBPC

(Edes, 2010) (North, Kehm, Bent, & Hartman, 2008)

Patient & Caregiver

MD

APRN

Psychologist

OT

Social Worker

Dietitian

Pharmacist

RN

Admin & Support

StaffChaplain

Other Home Care

Services

Medical Foster Home

The TEAM!!

PHYSICIAN

• Supervise overall patient care

• May admit patients or make home visits• Integral part of Treatment Plan development

and monitoring

APRN

• Assesses patient medical needs in home

• Primary medical management responsibility• Serves as a case manager to coordinate care

among the team members and specialties

RN

• Assesses patient’s needs in the home

• Fill mediplanners when appropriate

• Telephone triage on weekends

Social Worker

• Maximize benefits (VA and nonVA)

• Assesses veteran’s relationships

• Education for advance directives and DNR• Ongoing assessment of appropriateness for

HBPC program

Dietitian

• Ongoing assessment of nutritional status

• Recommends nutritional adjustments in management of chronic conditions

• Dietary guidance for current condition or prevention of exacerbations

Rehabilitation Therapist

• Ongoing assessment of functional status

• Home evaluation for structural modifications

• Determines need for medical equipment

• Establishes a therapeutic program to maximize functional independence

Pharmacist

Pharmacist

• Function under Scope of Practice

• Medication education (interprofessional,

patients, and students)

• Quality Assurance

Pharmacist

• Pharmaceutical Assessments:- Eliminate polypharmacy- Fall prevention- Identifying high risk or potentially inappropriate

meds for the elderly- Lab monitoring- Interactions (drug, food, herbal, disease state)- Renal & hepatic dose adjustment- Antibiotic selection

PsychologistWhy do we need a psychologist?? • 44% depression; 29% substance abuse; 24% anxiety or PDs; 21% PTSD;

20% schizophrenia; half of those over the age of 85 have dementia

Position Description: • Evaluation, diagnosis, and treatment of mental disorders• Assessment of cognitive deficits and functional capacities• Prevention services• Services for family caregivers, and couples/families• Behavioral medicine interventions• Communication/interaction among team members• Supervision/training

(Karel & Karlin, 2012)

PsychologistTop Ten themes of what we do:

• Educating team members on behavioral health issues and family dynamics• Increasing veteran access to mental health services• Helping team to develop strategies for working with veterans/families• Enhancing overall program quality/quality of care• Increasing holistic conceptualization/approach to patient care• Helping veterans and families to cope better• Supporting team development and cohesion• Contributing to team treatment planning and meetings• Being available for staff consultation and support

(Karel & Karlin, 2012)

The Effective Interprofessional Team

• Relationship development over time

• Understanding / respecting all roles

• Complementary skills

• Committed to a common goal

• Ongoing communication plan

(Sargeant, Loney, & Murphy, 2008)

Challenges

• Geographically challenging

• Changing the perception of services provided

• Establishing boundaries

• Patient goals: aggressive vs comfort

• Caregiver frailty

Success

• Improved transitions of care/referrals• Improved medication mgmt and adherence• Cost savings and better resource distribution• Team members: “our work has meaning”• Teaching site for interdisciplinary model• Achievement of our own “Service” = improved

team connection and access to recognition • Improved quality of life

(Hughes et al., 2000)

Central Arkansas VA: Home Based Primary Care

“Practitioner Nurse Rebecca Johnson: Dearest Home Health Team of the VA:

It was a real pleasure to have such a wonderful staff to attend to my husband. As far as I am concerned, you all are the best.

You and the staff showed the ultimate concern for him. You and the staff always would take time and ask him questions about how he felt and what you could do to help him. Thank you so much for being available for us. Mrs. Johnson, thank you for your training and trust in me. Each of you are very

special to me. You always brought cheer into our home every time you came. Thank you for your words of sympathy. You know how much I will miss him, but the Lord will help me to

endure. Thanks to all of you!”

Central Arkansas VA: Home Based Primary Care

Questions??

amanda.mccorkindale@va.govjulie.ruple@va.gov

BibliographyBeales, J. & Edes, T. (2009). Veteran’s affairs home based primary care. Clinics in

Geriatric Medicine (25), 149-154. Desai, N., Smith, K., & Boal, J. (2008). The positive financial contribution of home-

based primary care programs: the case of the mount sinai visiting doctor. Journal of American Geriatric Society (56) 4, 744-749.

Edes, T. (2010). Innovations in homecare: va home-based primary care. American Society on Aging (34) 2, 29-34.

Home Health Care Service Policy Memorandum No. HC-00C (June 24, 2014). Home health care service definition, objectives, and types of patients. Little Rock, AR.

Home Health Care Service Policy Memorandum No. HC-01 (June 17, 2014). Home based primary care mission, scope of care, and services. Little Rock, AR.

Home Health Care Service Policy Memorandum No. HC-08 (June 16, 2014). Admission to the HBPC program. Little Rock, AR.

BibliographyHughes, S., Weaver, F., Giobbie-Hurder, A., Manheim, L., Henderson, W., Kubal,

J.,…Cummings, J. (2000). Effectiveness of team-managed home-based primary care: a randomized multicenter trial. Journal of American Medical Association (284) 22, 2877-2885.

Karel, M. & Karlin, B. (2012). The VA HBPC mental health initiative: program implementation and preliminary outcomes. Gerontological Society of America Meeting. San Diego, CA. North, L., Kehm, L., Bent, K., & Hartman, T. (2008). Can home-based primary care cut

costs? The Nurse Practitioner (33) 7, 39-44. Sargeant, J., Loney, E., & Murphy, G. (2008). Effective interprofessional teams: “contact

is not enough” to build a team. Journal of Continuing Education of Health Professions Fall;28(4): 228-34.

US Department of Veterans Affairs. Information about home-based primary care. http://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!