Home-Based Primary Care Team Research Articles

Home and community-based services coordination for homebound older adults in home-based primary care

BackgroundMedically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients.MethodsAn online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members.ResultsNearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated ‘most’ or ‘all’ of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was ‘difficult.’ The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was ‘difficult’ or ‘very difficult’ to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05).ConclusionsDespite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

Fostering Excellence: An Examination of High-Enrollment VHA Medical Foster Home Programs.

This qualitative study aimed to assist the US Veterans Health Administration (VHA) to efficiently target recruitment into VHA Medical Foster Homes (MFHs) by understanding how high-enrollment MFH (HE-MFH) program attributes optimized MFH enrollment. We used an emergent exploratory design to study 3 HE-MFH programs across the United States. Data were collected from August 2013 through June 2014 through individual in-person and phone interviews and in-person focus group discussions with 39 MFH care providers. Three main themes emerged as essential for optimizing HE-MFH program enrollment: (1) alignment of right caregiver, right home, and right Veteran; (2) care practices that support caregiver, Veteran, and home-based primary care (HBPC); and (3) workplace practices and processes that demonstrate support of the MFH coordinator role by facility leadership and the HBPC team.

Launching Medical Foster Home Programs: Key Components to Growing This Alternative to Nursing Home Placement

ABSTRACTObjective: The objective of this research was to examine and explain elements that enhanced or thwarted program growth of the United States Veterans Health Administration Medical Foster Home program. Methods: This qualitative study was conducted nationally through individual interviews over the phone and in-person (n = 22) with coordinators (n = 15 at slow-growth programs; n = 6 at fast-growth programs), program support assistants (PSAs) (n = 1 at slow-growth program), and home-based primary care team members (n = 3), as well as three in-person focus groups (n = 28 total participants) with home-based primary care team members. All participants (N = 53) were involved with programs in existence for at least two years. Results: Facilitators and barriers that enhanced or thwarted program growth emerged around four themes: A full-time coordinator; Unmitigated home-based primary care team engagement; Pursuit and receipt of appropriate referrals; and Match between caregiver, home, and Veteran. Conclusions: To facilitate program growth, program leaders should consider themes identified and how to foster situations and shape policies that put themes into practice.

Independent Living Capacity Evaluation in Home-Based Primary Care: Considerations and Outcomes of a Quality Improvement Project

ABSTRACTObjectives: This article describes results of a quality improvement project review of 5 years of capacity evaluations for independent living conducted in one Home-Based Primary Care (HBPC) Program.Methods: A retrospective chart review was conducted for all patients evaluated for independent living capacity through the Boston VA HBPC Program (N = 25) to identify differences in outcomes for those with and without capacity. Descriptive information included referral sources, capacity decisions, time remaining in the home, and trajectory of patients following evaluation.Results: All patients evaluated had been diagnosed with a cognitive disorder, and on average, a relatively lower prevalence of mental illness compared with the national HBPC population. Referrals were made primarily by the HBPC team. Patients with capacity were found to have remained in their home longer than those who lacked capacity.Conclusions: Referral for a higher level of care was typically only recommended when no further intervention could be implemented and active risk in the home could not be managed.Clinical Implications: In home capacity evaluations are complex and challenging, yet results help family and HBPC team support patients’ preferences for staying in their own home as long as possible.

Allowing Family to be Family: End-of-Life Care in Veterans Affairs Medical Foster Homes

ABSTRACTThe Medical Foster Home program is a unique long-term care program coordinated by the Veterans Health Administration. The program pairs Veterans with private, 24-hour a day community-based caregivers who often care for Veterans until the end of life. This qualitative study explored the experiences of care coordination for Medical Foster Home Veterans at the end of life with eight Veterans’ family members, five Medical Foster Home caregivers, and seven Veterans Health Administration Home-Based Primary Care team members. A case study, qualitative content analysis identified these themes addressing care coordination and impact of the Medical Foster Home model on those involved: (a) Medical Foster Home program supports Veterans’ families; (b) Medical Foster Home program supports the caregiver as family; (c) Veterans’ needs are met socially and culturally at the end of life; and (d) the changing needs of Veterans, families, and caregivers at Veterans’ end of life are addressed. Insights into how to best support Medical Foster Home caregivers caring for Veterans at the end of life were gained including the need for more and better respite options and how caregivers are compensated in the month of the Veteran’s death, as well as suggestions to navigate end-of-life care coordination with multiple stakeholders involved.

Assessing Patients' Disaster Preparedness in Home-Based Primary Care

Background: Chronic conditions paired with normal aging put home-bound individuals at risk of harm during a disaster. Because of their high rate of comorbidities, veterans receiving care from the Veterans Health Administration (VHA)'s home-based primary care (HBPC) program are especially vulnerable, which may prevent them from being prepared for disaster. With intimate knowledge of their patients' home environments, medical needs, resources, and limitations, HBPC practitioners are uniquely positioned to assess and improve disaster preparedness of patients. Objective: This study explored issues regarding disaster preparedness for HBPC patients, including ways in which policy and procedures support routine assessment of disaster preparedness for patients as well as patient education activities. Methods: This project involved 32 semi-structured interviews with practitioners and leadership at 5 VHA HBPC programs - 3 urban and 2 rural. Transcripts of the interviews were analyzed using content analysis techniques. Results: Three themes emerged regarding the assessment of a patient's disaster preparedness: (1) assessment tools are rudimentary and, in some cases, individually developed by practitioners; (2) comprehension of criteria for assigning risk categories varies among practitioners, and (3) patients' cognitive impairment, limited resources, and out-of-date or inaccessible materials are the primary challenges to their preparedness. A fourth additional theme emerged as well: (4) the interdisciplinary nature of the HBPC team allows for unique innovative practices, such as a central focus on caregiver support and personal safety, as it relates to assessment and preparedness of the patient. Conclusion: Health and functional limitations may prevent home-bound patients from being adequately prepared for disasters. Standardized strategies and tools concerning disaster preparedness assessment for HBPC patients, which allow flexibility in consideration of factors such as local hazards, could assist in creating more comprehensive planning approaches and, in turn, more prepared persons. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel

Veterans Have New Place to Call Home

LOUISVILLE, KY – A novel concept in nursing home-level care – medical foster care – is providing a viable alternative for veterans who meet the requirements for nursing home care but who prefer to live in a more home-like setting. “Medical foster care provides an alternative site of care to meet the increasing demand for long-term care services,” according to June Leland, MD, medical director of the Department of Veterans Affairs Home Based Primary Care (HBPC) Program in Tampa, FL, which provides oversight of the foster care program. The program also provides longitudinal medical care to veterans enrolled in the program. Dr. Leland described the program in a poster presented at the AMDA 2015 Annual Conference. Medical foster homes offer a community-based living arrangement for veterans in need of room and board, but who require round-the-clock supervision for safety and personal care due to physical or mental impairments or disabilities, she explained in an interview. The VA serves many such veterans who prefer home-based care to nursing home care, she said. VA HBPC teams coordinate the placements in private homes with specially trained caregivers. Care is taken to ensure that placements are well-matched, taking into consideration the veteran’s health care needs and the caregiver’s skills and training. Caregivers provide a range of services, including ventilator support, mental health care for the seriously mentally ill, care for those with spinal cord injuries, and care for the frail elderly. Care may include end-of-life care and preventative care, and it can be personalized and customized for those in need who might otherwise live alone with inadequate support, Dr. Leland said. He noted that caregivers often are individuals who have previously cared for a spouse or family member and who have developed the unique skills necessary for providing quality care. The relationships between the caregivers and residents range from skilled nurse to surrogate family member, depending on the resident’s needs and desires, she said. Medical foster care also is cost-effective. The program has been shown to reduce hospitalizations and emergency room visits, and it is self-sustaining through avoidance of the high costs associated with care in LTC facilities, which total about $100 per day to taxpayers for the care of veterans, she said. In Tampa, the average fee paid by medical foster home residents is $2,292 per month – $214 per day lower than the average cost of nursing home care – resulting in a savings of $78,110 annually. Additional savings are seen due to the earlier hospital discharges, shorter lengths of stay, and decreased admissions, Dr. Leland said. Since its inception in 2000, the medical foster care program has grown from a single site to more than 45 sites across the country with a total of 561 caregivers. The average length of stay in foster care is 315 days, and the total cost savings in fiscal year 2013 was $31 million over projected costs of nursing home care, assuming all foster care residents were eligible for VA payment of nursing home care, she said. The medical foster care program is proving extremely successful and rewarding for both residents and caregivers, she said, and it continues to grow. “These are really good and kind people,” she said of the caregivers, who she said seem to find great purpose in caring for these veterans in need.

Better access, quality, and cost for clinically complex veterans with home-based primary care.

In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.

Analyzing the Interprofessional Working of a Home-Based Primary Care Team.

Increasingly, interprofessional teams are responsible for providing integrated health care services. Effective teams, however, are not the result of chance but require careful planning and ongoing attention to team processes. Based on a case study involving interviews, participant observation, and a survey, we identified key attributes for effective interprofessional working (IPW) within a home-based primary care (HBPC) setting. Recognizing the importance of a theoretical model that reflects the multidimensional nature of team effectiveness research, we employed the integrated team effectiveness model to analyze our findings. The results indicated that a shared vision, common goals, respect, and trust among team members – as well as processes for ongoing communication, effective leadership, and mechanisms for conflict resolution – are vital in the development of a high-functioning IPW team. The ambiguity and uncertainty surrounding the context of service provision (clients' homes), as well the negotiation of external relationships in the HBPC field, require further investigation.

National Integration of Mental Health Providers in VA Home-Based Primary Care: An Innovative Model for Mental Health Care Delivery With Older Adults

To promote mental health (MH) service access and quality for veterans with complex and chronic medical, social, and behavioral conditions, the U.S. Department of Veterans Affairs (VA) has integrated a full-time MH provider into each VA home-based primary care (HBPC) team. The goal of the current evaluation is to examine the nature and extent to which MH care processes and practices have been integrated into HBPC nationally. Separate surveys assessing the integration of a wide range of MH care practices and HBPC team processes were sent to MH providers and program directors in each HBPC program in 2010. A total of 132 MH providers representing 119 HBPC programs, and 112 program directors completed the surveys. The most common clinical issues addressed by MH providers were depression, coping with illness and disability, anxiety, caregiver/family stress, and cognitive evaluation. Other team members typically conducted initial MH screenings, with MH providers' time focusing on cases with identified needs. Approximately 40% of MH providers' time was devoted to direct clinical care. Significant time was also spent on team activities, driving, and charting. Integration of MH services into HBPC is feasible and facilitates service access for a vulnerable population. Mental health care delivery in HPBC generally involves a high degree of interdisciplinary practice. Mental health integration into HBPC may serve as a model for other systems interested in promoting MH care delivery among homebound and other older individuals.

Enhancing Provider Knowledge and Patient Screening for Palliative Care Needs in Chronic Multimorbid Patients Receiving Home-Based Primary Care

This article describes a pilot model to increase palliative care (PC) knowledge and collaboration among providers and to systematically identify chronic multimorbid home care patients who would benefit from focused discussion of potential PC needs. Thirty health care providers from a home-based primary care team attended interdisciplinary trainings. The Palliative Performance Scale (PPS) tool was used to trigger discussions of potential palliative needs at team rounds for patients who scored below a cutoff point on the tool. Palliative Performance Scale implementation added little burden on nurses and triggered a discussion in 51 flagged patients. The tool successfully identified 75% of patients who died or were discharged. Screening was systematic and consistent and resulted in targeted discussions about PC needs without generating additional burden on our PC consult service. This model shows promise for enhancing collaborative patient care and access to PC.

Integrating care coordination home telehealth and home based primary care in rural Oklahoma: A pilot study.

The purpose of this program was to evaluate the benefits of integrating VA Care Coordination Home Telehealth and Telemental health within HBPC. A case study design was used to determine quality assurance and quality improvement of incorporating additional home telehealth equipment within Home Based Primary Care (HBPC). Veterans with complex medical conditions and their caregivers living in rural Oklahoma were enrolled. Veterans received the same care other HBPC patients received with the addition of home telehealth equipment. Members from the interdisciplinary treatment team were certified to use the telehealth equipment. Veterans and their caregivers were trained on use of the equipment in their homes. Standard HBPC program measures were used to assess the program success. Assessments from all disciplines on the HBPC team were at baseline, 3, and 6 months, and participants provided satisfaction and interview data to assess the benefits of integrating technology into standard care delivery within an HBPC program. Six veterans were enrolled (mean age = 72 yrs) with a range of physical health conditions including: chronic obstructive pulmonary disease, cerebrovascular accident, spinal cord injury, diabetes, hypertension, and syncope. Primary mental health conditions included depression, dementia, anxiety, and PTSD. Scores on the Mini-Mental State Examination ranged from 18 to 30. Over a 6-month period, case studies indicated improvements in strength, social functioning, decreased caregiver burden, and compliance with treatment plan. This integration of CCHT and HBPC served previously underserved rural veterans having complex medical conditions and appears both feasible and clinically beneficial to veterans and their caregivers.

Appropriateness of Medication Prescribing Using the STOPP/START Criteria in Veterans Receiving Home-Based Primary Care

To evaluate the appropriateness/inappropriateness of medication prescribing using the Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) criteria in elderly homebased primary care (HBPC) veterans and to understand the potential impact of the HBPC team on the STOPP/START criteria. Retrospective chart review between September 1, 2007, and September 30, 2009. Edward Hines, Jr. VA Hospital, Hines, Illinois, a tertiary care referral center. Two hundred patients 65 years of age and older who had an initial interdisciplinary evaluation conducted by the HBPC team. Exclusion criteria included admission to the hospital between the initial and follow-up medication review, admission to the HBPC program for palliative or hospice care, or death before completion of a follow-up evaluation. Appropriateness/inappropriateness of medication prescribing was assessed by comparing the medication list at the initial pharmacist medication review and follow-up review. Initial and follow-up STOPP and START scores were calculated for each patient. The primary outcome was to evaluate the appropriateness/inappropriateness of medication prescribing using the STOPP/START criteria. The secondary outcome was to understand the potential impact of the HBPC team on the STOPP/START criteria. There was a statistically significant decrease in the STOPP score between the initial and follow-up medication review (P = 0.0014). There was not a statistically significant increase in the START score between the initial and follow-up medication review (P = 0.5720). A statistically significant decrease in the STOPP score was found. Although the START score increased, the change was not found to be statistically significant.