Home-Based Primary Care Program Research Articles

Symptom Management over Time Among Homebound Patients Receiving Home-Based Primary and Palliative Care (SA527-A)

1.Review changes in symptom burden over time among chronically ill homebound.2.Describe management of symptoms among homebound patients receiving home-based primary care services. Increasing numbers of patients, many of whom are frail and elderly, are living with multiple chronic medical conditions and functional impairments that leave them homebound. Home-based primary care (HBPC) programs provide access to healthcare services for this vulnerable population. The Mount Sinai Visiting Doctors Program (MSVD) is a primary and palliative care program that cares for over 1,000 homebound patients annually. Our previous study showed that homebound patients have high symptom burden upon program entry including pain (47%) presumably due to the conditions and/or treatments that contribute to their homebound state. Yet little is known as to how individual symptoms are treated at home and how they respond to intervention, especially over longer time periods. The purpose of this study was to see how symptoms change over time following HBPC enrollment. HBPC patients who reported any symptoms on the Edmonton Symptom Assessment Scale (ESAS) at program entry between 2008 and 2010 were eligible for telephone ESAS follow-up at 3 week and 12 week intervals. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow up care, interdisciplinary care management including social work, and urgent in home care as necessary. Paired t-tests assessed change between baseline and subsequent time points. 130 patients were followed. For each individual symptom, among those with baseline moderate or severe symptoms, mean symptom score decreased at 3 week follow up (p < .05). Patient pain, anxiety, depression, lack of well-being, loss of appetite, drowsiness, nausea, and tiredness remained significantly decreased at 12 week follow-up. In a non-hospice chronically ill population of urban homebound, patient symptoms can be successfully managed in the home.

Assessing Health Status Differences Between Veterans Affairs Home-Based Primary Care and State Medicaid Waiver Program Clients

Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers. Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008. The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size. Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P < .001), Chronic obstructive pulmonary disease (z = 3.9; P < .001), and cancer (z = 8.5; P < .001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease. With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes.

Incidence of Venous Thromboembolism in a Homebound Population

Venous thromboembolism (VTE) is a source of morbidity and mortality for high risk populations. The incidence of VTE has been characterized in many populations, but the incidence in homebound patients, a growing demographic, is unknown. The objective of this study was to estimate the incidence of VTE occurring at home in a cohort of patients enrolled in the Mount Sinai Visiting Doctor's Program (VDP), a home-based primary care program. The medical records of patients enrolled in the VDP over a 4 year period were examined. Incident VTE in a home setting was defined as the diagnosis of any symptomatic deep vein thrombosis or pulmonary embolism that did not occur during a hospitalization, within 4 weeks of a medical hospitalization, or within 12 weeks of a hospitalization for surgery. Functional status was abstracted for all patients, when available. Of 1,910 patients active during the study period, 39 cases of at-home VTE were identified (8.0 per 1,000 person years [95 % CI = 7.6-8.3]). Of these events, 30 of 39 were confirmed by radiological testing and considered definite, and 9 were considered probable. There was no statistically significant difference in age, race, or sex between the patients with and without VTE. In conclusion the estimated incidence of symptomatic VTE in a homebound population is low. There is insufficient evidence to support routine surveillance or prophylaxis strategies for VTE in homebound patients.

Assessing Readiness to Change of a High Fall Risk Patient: A Case Report

The case report discusses a patient with an extensive history offalls living in the community. The patient's medical record was analyzed and an informal interview was conducted with the patient to provide an overview of his care provided by the Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) program from June 2008 to February 2011. The report will also apply the transtheoretical model of behavioral change to discuss the behavior change process of a high fall risk patient. Applying this model to the high fall risk population may assist with decreasing the frustration of clinicians and caregivers, as it acknowledges the "smaller gains" with fall prevention.

Seasonal Influenza Vaccination among Homebound Elderly Receiving Home-Based Primary Care in New York City

Seasonal influenza vaccination is recommended for all persons aged ≥50 years to reduce influenza related morbidity and mortality, but vaccination coverage among community-dwelling elderly remains low. Homebound elderly receiving home-based primary care (HBPC) have fewer barriers to vaccination than other community-dwelling elderly. The Mount Sinai Visiting Doctors (MSVD) program provides HBPC to homebound elderly in New York City. This study assessed seasonal influenza vaccination coverage within an urban HBPC program and identified factors associated with vaccine refusal. A cross-sectional analysis of data from the 2008-2009 influenza season was completed and influenza vaccination coverage was assessed. The association between social, demographic and health-related characteristics and vaccine refusal was evaluated using bivariate analysis and multivariable logistic regression. Of 689 people aged >65 eligible for influenza vaccination, 578 (84%) accepted and 111 (16%) refused vaccination. In multivariable analysis, vaccine refusal was positively associated with female gender (adjusted odds ratio [AOR] = 1.85, 95% confidence interval [CI] 1.02, 3.35), black race (AOR = 2.04, 95% CI 1.28, 3.25), and living alone (AOR = 1.71, 95% CI 1.10, 2.67), and negatively associated with dementia (AOR = 0.59, 95% CI 0.37, 0.91). Seasonal influenza vaccine coverage in the MSVD program was high compared to nursing home and community-dwelling elderly. Offering patients vaccination at home without additional expense will likely improve vaccine coverage among urban homebound elderly. Understanding why vaccine refusal rates are higher among females, black patients, and those living alone should guide interventions to increase vaccine acceptance among this population.

To the Hospital and Back Home Again: A Nurse Practitioner-Based Transitional Care Program for Hospitalized Homebound People

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.

Translation of a Dementia Caregiver Support Program in a Health Care System—REACH VA

Based on the National Institute on Aging/National Institute of Nursing Research Resources for Enhancing Alzheimer's Caregiver Health (REACH) randomized controlled trial (REACH II), REACH VA (Department of Veterans Affairs) was the first national clinical translation of a proven behavioral intervention for dementia caregivers, running from September 2007 through August 2009. This article describes the population and outcomes of the REACH VA translation of REACH II into the VA. Clinical staff members from 24 VA Medical Center Home-Based Primary Care programs in 15 states delivered the intervention to stressed caregivers of patients with dementia. Like REACH II, the 6-month REACH VA intervention, structured through a protocol and individualized through a risk assessment, targeted education, support, and skills training to address caregiving risk areas of safety, social support, problem behaviors, depression, and health through 12 individual in-home and telephone sessions and 5 telephone support group sessions. Staff members of the Memphis VA Medical Center, Memphis, Tennessee, collected data on burden, depression, health and healthy behaviors, caregiving frustrations, social support, dementia-related behaviors, and time spent providing care and on duty. From baseline to 6 months, caregivers reported significantly decreased burden, depression, impact of depression on daily life, caregiving frustrations, and number of troubling dementia-related behaviors. A 2-hour decrease in hours per day on duty approached significance. Caregivers (96%) believed that the program should be provided by the VA to caregivers. This clinical translation achieved outcomes similar to the REACH II randomized controlled trial, providing clinically significant benefits for caregivers of a veteran with a progressive dementing disease. This model of caregiver support can inform public policy in providing assistance to caregivers.

Hospitalizations and Skilled Nursing Facility Admissions Before and After the Implementation of a Home‐Based Primary Care Program

To evaluate the effect of an urban house calls program (HCP) on healthcare utilization. Retrospective chart review with pre/post analysis. Urban home-based primary care program. All participants (N=179) in a capitated insurance program enrolled in a HCP between October 2004 and August 2006. Enrollment into HCP. Hospitalizations and skilled nursing facility (SNF) admissions before and after enrollment. Patients with at least one hospitalization or SNF admission before and after enrollment were compared using the McNemar test. Median number of hospitalizations and SNF placements before and after HCP enrollment were compared using the Wilcoxon signed-rank sum test. Sixty-one percent of patients had one or more hospitalizations before enrollment, whereas only 38% had one or more hospitalizations after enrollment (P<.001). Thirty-eight percent of patients had at least one SNF placement before enrollment, compared with 18% after enrollment (P=.001). The median hospitalization rate decreased from 1 to 0; the median SNF placement rate was 0 (interquartile range 0-1) before enrollment and 0 (interquartile range 0-0) after enrollment (P<.001). A HCP may be associated with fewer hospitalizations and SNF placements. Models of care that reduce morbidity and preserve quality of life are critical to help homebound older adults remain in their communities.

Understanding and Improving the Burden and Unmet Needs of Informal Caregivers of Homebound Patients Enrolled in a Home-Based Primary Care Program.

The growing homebound population is heavily reliant on informal caregivers, who are increasingly burdened by their roles. This study describes informal caregivers of the homebound who remain caregivers at a 9-month follow-up and examines the impact of a home-based primary care (HBPC) program on caregiver burden and unmet needs using a prospective design with a pre-post intervention assessment. Informal caregivers of the urban homebound are similar to caregivers of other populations and have a broad range of unmet needs. The intervention described is the regular provision of multidisciplinary HBPC. Hundred fourteen caregivers of newly admitted patients complete a baseline interview. For the 56 caregivers who complete a 9-month follow-up interview, participation in HBPC is associated with a statistically significant decrease in overall caregiver burden. At 9 months, caregivers demonstrate an overall decrease in unmet needs, with a statistically significant decrease across two measured domains. These results suggest that the regular provision of multidisciplinary care in the home can mitigate the deleterious impact of informal caregiving.

Impact of a Home-Based Primary Care Program in an Urban Veterans Affairs Medical Center

Describe how an interdisciplinary home-based primary care program (HBPC) affected hospital and emergency department (ED) use in an urban Veterans Affairs medical center. A retrospective review. HBPC of the Washington, DC, Veterans Affairs Medical Center (VAMC-DC). All HBPC patients enrolled for at least 6 months during the period of January 1, 2001 through December 31, 2002. Baseline demographic variables (such as age, gender, race, living arrangement, community services used), major medical diagnoses, functional measures (MMSE, ADL, IADL, Braden), advance directives, episodes of ED, and hospital use for the 6-month period before and after HBPC enrollment from the VAMC-DC and discharge status (obtained from electronic medical records). A total of 183 patients were enrolled in HBPC for at least 6 months during the 24-month study period. Ninety-five percent were male with a mean age of 73.6 years (range 36 to 95). Most were African American (71%) and lived with a caregiver (65%). The average number of comorbidities was 6 per patient. At the end of the 2-year study period, 45% remained active in HBPC and 17% had died. Using paired score analysis t tests, patients enrolled in HBPC for 6 months had 43.7% fewer hospital admissions (P = .001) and spent 49.9% fewer days in the hospital (P = .001). The 18.5% reduction in ED visits was not statistically significant (P = .2632). Use of HBPC for 6 months for frail chronically ill patients in an urban VAMC may be associated with fewer hospital admissions resulting in reduced total hospital days, but no significant change in ED use.

The Positive Financial Contribution of Home‐Based Primary Care Programs: The Case of the Mount Sinai Visiting Doctors

The coming decade will see a rise in the number of homebound seniors. These vulnerable patients have great difficulty accessing primary care. Home-based primary care (HBPC) can fill this healthcare need. Presently, such programs have been slow to develop, in part because of the perception that they are fiscal liabilities. Using the Mount Sinai Visiting Doctors (MSVD) program, the total financial effect of an HBPC program on an Academic Health Center (AHC) was assessed. A retrospective cohort analysis (n=692, 565 patient years) of Medicare-eligible individuals who were enrolled in the MSVD HBPC program was conducted. Revenues and associated costs for direct physician home care services, inpatient admissions, and outpatient clinic and emergency department visits for 1 calendar year were captured. Sensitivity analyses varying efficiency and cost variables were performed. Total direct cost for HBPC for the patient cohort was $976,350. Direct billing from home visits generated revenues that covered 24% of total direct care costs. Over a 12-month period, the cohort had 398 inpatient admissions and 1,100 non-HBPC outpatient visits, generating an overall contribution to margin of nearly $2.6 million. It is likely that this analysis underestimates the true contribution to margin, because it does not capture patient encounters at specialty clinics not in the Department of Medicine, unaffiliated medical centers, or private community-based practices. Although direct billing for HBPC programs does not generate enough revenue to meet operating costs, they can be significant revenue generators for the wider healthcare system and thus are fiscally worthy of subsidization.

Novel Surveillance Activities in a Home-Based Primary Care Program

Novel Surveillance Activities in a Home-Based Primary Care Program

Use of the Electronic Record in the Home-Based Primary Care Programs of the Department of Veterans Affairs Health Care System

Use of the electronic record in the Home-Based Primary Care (HBPC) programs of the Department of Veterans Affairs (VA) Health Care System is described. The VA electronic record is a complete computerized system for a patient's record. The use of this system provides instant information on the health status of each patient referred to and managed by home care.

Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans

Background: The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness. Objective: The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program. Methods: A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated. Results: Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study ( P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period. Conclusions: By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.

A Multidisciplinary Program for Delivering Primary Care to the Underserved Urban Homebound: Looking Back, Moving Forward

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

The involvement of physicians in VA home care: results from a national survey.

To examine the role of physicians in the Veteran Affairs (VA) home-based primary care (HBPC) program and to identify variables that predict whether physicians make home visits and volume of home visits made. Descriptive and regression analyses of responses from a mail survey. Forty-five physicians affiliated with VA HBPC programs. MAIN SURVEY TOPICS: Self-reported work load, attitudes toward home care, reasons for home visits, administrative policies regarding physicians' role in patient care management, and time commitment to home care. A majority of physicians believed strongly in the importance of home care and made home visits for reasons consistent with their training. Physician attitude toward home care and preoccupation with office or hospital practice were related to whether or not physicians made home visits. Degree of preoccupation with office practice and amount of salary support from VA HBPC were significant predictors of the number of visits made (R2 = 0.44). These findings indicate that most physicians will make home visits if they believe that home care is valuable and if their time commitment is supported financially. Managed care plans that own and operate home care programs and have the capacity to transfer primary care management to physicians who derive financial support from the programs should find this information particularly relevant.