The Evolution of The Evolution of the SLVCS the SLVCS Hospital at Home Hospital at Home ProgramProgram

Lumie Kawasaki, M.D., M.B.A.Lumie Kawasaki, M.D., M.B.A.

March 24, 2011March 24, 2011

ObjectivesObjectives

• To provide an understanding of the general Hospital To provide an understanding of the general Hospital at Home model in the context of other home care at Home model in the context of other home care models. models.

• To describe the formation and development of the To describe the formation and development of the SLVHCS Hospital at Home programSLVHCS Hospital at Home program

• To provide a current snapshot of the SLVHCS H@H To provide a current snapshot of the SLVHCS H@H program. program.

• To identify benefits, limitations, lessons learned; To identify benefits, limitations, lessons learned; and and

• To describe the next phase in development To describe the next phase in development

Hospital at Home Model Hospital at Home Model Arose from a need for alternative Arose from a need for alternative models to reduce reliance on inpatient models to reduce reliance on inpatient care due to: care due to: • excess demand over supply of excess demand over supply of

acute hospital beds, acute hospital beds, • growing health care technology, growing health care technology, • greater emphasis on cost-greater emphasis on cost-

containment measures containment measures • inpatient care may not always inpatient care may not always

produce optimal clinical outcomes produce optimal clinical outcomes for some groups of patients – for some groups of patients – particularly the elderly.particularly the elderly.

BackgroundBackgroundHospital at Home is an alternative Hospital at Home is an alternative model to inpatient caremodel to inpatient care

• International modelInternational model• Types: “early-discharge” “substitution”Types: “early-discharge” “substitution”• Meta-analysisMeta-analysis• improved patient satisfactionimproved patient satisfaction•clinical outcomes with traditional clinical outcomes with traditional hospitalizationhospitalization

•Johns Hopkins/Bruce Leff, MDJohns Hopkins/Bruce Leff, MD•Portland VAMC/Scott Mader, MDPortland VAMC/Scott Mader, MD

•Hawaii VAMCHawaii VAMC

BackgroundBackground

The post-Katrina environment had:The post-Katrina environment had:

– Reduced hospital bed capacity and crowded ERs Reduced hospital bed capacity and crowded ERs due to multiple hospital closures, including the due to multiple hospital closures, including the SLVHCS-based Inpatient Services. SLVHCS-based Inpatient Services.

– Greater reliance on local non-VA hospitals (33), Greater reliance on local non-VA hospitals (33), and other VA hospitals within VISN 16, leading and other VA hospitals within VISN 16, leading to fragmented care, redundant diagnostic to fragmented care, redundant diagnostic studies. studies.

– Highlighted the vulnerabilities of older adults Highlighted the vulnerabilities of older adults with higher mortality and depression post-with higher mortality and depression post-Katrina. Katrina.

– Exponential growth in the SLVHCS veteran Exponential growth in the SLVHCS veteran population (151%) as veterans returned “homepopulation (151%) as veterans returned “home

SLVHCS Hospital at Home opened October 1, 2007 to SLVHCS Hospital at Home opened October 1, 2007 to help address some of these needs… help address some of these needs…

The Concept of HomeThe Concept of Home

Physical StructurePhysical Structure TerritoryTerritory Locus in spaceLocus in space Self and self-identitySelf and self-identity Social and cultural unitSocial and cultural unit FamiliarFamiliar CenterCenter ProtectorProtector HealerHealer

““The image of a physician delivering care to a sick The image of a physician delivering care to a sick patient at home is one of the essential and patient at home is one of the essential and enduring images in the collective consciousness of enduring images in the collective consciousness of medicine. It is an image that no doubt once medicine. It is an image that no doubt once inspired, and perhaps still inspires, some to pursue inspired, and perhaps still inspires, some to pursue a career in medicine. It is an image from which a career in medicine. It is an image from which the medical profession, as a whole, once drew the medical profession, as a whole, once drew inspiration so as to say “Yes, this is what inspiration so as to say “Yes, this is what physicians are about. Physicians take care of physicians are about. Physicians take care of patients.” patients.”

Leff, B. “The Future History of Home Care and Physician House Leff, B. “The Future History of Home Care and Physician House Calls in the United States,” 2001Calls in the United States,” 2001

Uniqueness of Home VisitsUniqueness of Home Visits

Qualitative interview study performed, as part of a large randomized Qualitative interview study performed, as part of a large randomized psychosocial intervention study on the effects of home visit to Danish psychosocial intervention study on the effects of home visit to Danish patients with colorectal cancer. N=21 informants. patients with colorectal cancer. N=21 informants.

““Healthcare interventions in patients’ homes result in a Healthcare interventions in patients’ homes result in a well-balanced contactwell-balanced contact between the professional visitor and the patient by overcoming the barrier felt between the professional visitor and the patient by overcoming the barrier felt by patients in the hospital setting, where they are sometimes treated as by patients in the hospital setting, where they are sometimes treated as objects. Meeting patients in their home setting gave the visitor a deeper objects. Meeting patients in their home setting gave the visitor a deeper understanding of them as persons and facilitated dialogue about their daily understanding of them as persons and facilitated dialogue about their daily lives, problems, social network, and social resources.” lives, problems, social network, and social resources.”

Ross, L, et al. Cancer Nursing. Ross, L, et al. Cancer Nursing. 20022002

Improved balance of powerImproved balance of power

Uniqueness of Home VisitsUniqueness of Home Visits

N=200 N=200 Prospective, repeated-measures design study, focusing on patient safety Prospective, repeated-measures design study, focusing on patient safety

and caregiver issues. and caregiver issues. Compared the yield of a clinic-based home assessment with the yield of Compared the yield of a clinic-based home assessment with the yield of

a home visit involving patients with dementia. a home visit involving patients with dementia. 84% of serious problems were identified only at home visit, not at clinic 84% of serious problems were identified only at home visit, not at clinic

visit. Issues: social isolation, caregiver stress, fall risk. visit. Issues: social isolation, caregiver stress, fall risk.

Ra,sde;;. KW. et al, Ra,sde;;. KW. et al, Alzheimer Dis Assoc Disord, Alzheimer Dis Assoc Disord, 20042004

Understanding the client’s health need as he or Understanding the client’s health need as he or she sees itshe sees it

It is difficult to express in words the difference It is difficult to express in words the difference between knowing patients by their visits to the between knowing patients by their visits to the office and knowing them as a visitor to their homes. office and knowing them as a visitor to their homes. The home is where a family’s values are expressed. The home is where a family’s values are expressed. It is in the home that people can be themselves. It is in the home that people can be themselves. The history of the family – its story, its joys and The history of the family – its story, its joys and sorrows, its memories and aspirations are this sorrows, its memories and aspirations are this reason assessment in the home is different from reason assessment in the home is different from assessment in the office or the hospital. Instead of assessment in the office or the hospital. Instead of asking about activities of daily living, we see asking about activities of daily living, we see patients in their own bedroom, bathroom, and patients in their own bedroom, bathroom, and kitchen, climbing their own stairs, and so on. When kitchen, climbing their own stairs, and so on. When we review the medications, we can assemble them we review the medications, we can assemble them all-including those from the bathroom cabinet—by all-including those from the bathroom cabinet—by the bedside or on the kitchen table. We can sense the bedside or on the kitchen table. We can sense for ourselves either the peace or the tension in the for ourselves either the peace or the tension in the home. We can meet with the family on their own home. We can meet with the family on their own ground, where they are most likely to express their ground, where they are most likely to express their feelings. In the home the patient can be in control feelings. In the home the patient can be in control of his or her own care, and this can be a powerful of his or her own care, and this can be a powerful influence on healing. influence on healing.

McWhinney, Ian R. McWhinney, Ian R.

Uniqueness of Home CareUniqueness of Home Care

Equal balance of powerEqual balance of power Understanding of patient’s health needs as he or she sees Understanding of patient’s health needs as he or she sees

itit Community connections Community connections Social model -- Social model --

– Improved understanding of physiological/psychological Improved understanding of physiological/psychological aspects of one’s diseaseaspects of one’s disease

– Improved copingImproved coping– Enhanced social supports and contactsEnhanced social supports and contacts– Improved knowledge of community resourcesImproved knowledge of community resources– Broader understanding of patient on part of the health Broader understanding of patient on part of the health

professionalprofessional

Home Care ModelsHome Care Models

PreventivePreventive

Transitions of careTransitions of care

Primary Care/Long-Primary Care/Long-termterm

Acute Care ModelAcute Care Model

Preventive CarePreventive Care

Meta-analysis, 15 studies Meta-analysis, 15 studies – 9 studies to general elderly population9 studies to general elderly population– 6 studies to older adults at risk for adverse events6 studies to older adults at risk for adverse events

Significant impact on mortality, admissions to long-term care institutions.Significant impact on mortality, admissions to long-term care institutions.Elkan R, et al. BMJ 2001Elkan R, et al. BMJ 2001

3-year RCT, N=215, 75+yo, Geriatric APN in collaboration with 3-year RCT, N=215, 75+yo, Geriatric APN in collaboration with geriatrician. Annual CGA with quarterly follow-up. geriatrician. Annual CGA with quarterly follow-up.

Significant impact on disability (ADLs) and permanent nursing home Significant impact on disability (ADLs) and permanent nursing home stays. stays. Stuck A et al. NEJM 1994Stuck A et al. NEJM 1994

3-year stratified randomized trial, 75+yo, RN in collaboration with 3-year stratified randomized trial, 75+yo, RN in collaboration with geriatrician. Annual CGA with quarterly follow-up.geriatrician. Annual CGA with quarterly follow-up.

Reduce risk for elderly at low risk, but not at high risk for functional Reduce risk for elderly at low risk, but not at high risk for functional impairment. impairment. Stuck A et al. Arch Int Med 2000Stuck A et al. Arch Int Med 2000

Transitional CareTransitional Care

Care Transition CoachingCare Transition Coaching– APN “transition coach,” begin in hospital and 30-day post-dischargeAPN “transition coach,” begin in hospital and 30-day post-discharge– Encourages family caregivers to assume more active roles during care transitions, focusing on med Encourages family caregivers to assume more active roles during care transitions, focusing on med

mgmt, follow-up with physician, red flag list. Personal health record maintained by pt/caregiver. mgmt, follow-up with physician, red flag list. Personal health record maintained by pt/caregiver. – Lower all-cause re-hospitalization rate at 30 and 90 days reduced. Lower costsLower all-cause re-hospitalization rate at 30 and 90 days reduced. Lower costs . . (Coleman et al, Arch Int (Coleman et al, Arch Int

Med, 2006)Med, 2006)

APN transitional care modelAPN transitional care model– APN-directed, begin in hospital, arranges post-discharge plans. 7-day per week APN-directed, begin in hospital, arranges post-discharge plans. 7-day per week

telephone access. telephone access. – 3 RCTs: greater pt satisfaction, lower readmissions, decreased costs. 3 RCTs: greater pt satisfaction, lower readmissions, decreased costs.

CHF/Disease ManagementCHF/Disease Management– Post-discharge visit by RN, pharmacist, or cardiac nurse within 7-14 days for structured, Post-discharge visit by RN, pharmacist, or cardiac nurse within 7-14 days for structured,

comprehensive visit, including barriers to treatment adherence (e.g. social support). 3-6 comprehensive visit, including barriers to treatment adherence (e.g. social support). 3-6 years.years.

– Reduced all-cause mortality, longer survival, longer event-free survival, fewer unplanned Reduced all-cause mortality, longer survival, longer event-free survival, fewer unplanned readmissions, shorter hospital stay if admitted, fewer ICU admissions. readmissions, shorter hospital stay if admitted, fewer ICU admissions. (Ahern MM et al, (Ahern MM et al, Disease Management, 2007; Simon S et al, Circulation, 2002)Disease Management, 2007; Simon S et al, Circulation, 2002)

Primary/Long-Term CarePrimary/Long-Term Care

VA- Home-Based Primary CareVA- Home-Based Primary Care

Physician Home Visiting ProgramPhysician Home Visiting Program

VA Home-Based Primary CareVA Home-Based Primary Care

Differences Between VA HBPC and Medicare Home Care

   

VA HBPC Medicare Home Care

Targets complex chronic disease Remediable conditions

Comprehensive primary care Specific problem-focused

Skilled care not required Requires skilled care

Strict homebound not required Must be homebound

Accepts declining status Requires improvement

Interdisciplinary team One or multidisciplinary

Longitudinal care Episodic, post-acute care

Reduces hospital days No definitive impact

Limited geography and intesnity Anywhere; anytime

Clinician Rankings of Factors Influencing Clinician Rankings of Factors Influencing House CallsHouse Calls

N=36 N=36 10-point scale reflecting weight of influence10-point scale reflecting weight of influence Motivators: Motivators:

– Improved patient careImproved patient care– AutonomyAutonomy– Positive experience with house callPositive experience with house call

Barriers:Barriers:– Lack of training regarding house callsLack of training regarding house calls– InconvenientInconvenient– Inadequate compensationInadequate compensation

Landers SH et al, Case Management Journals 10 (3), 2009Landers SH et al, Case Management Journals 10 (3), 2009

Clinician Rankings of Factors Influencing Clinician Rankings of Factors Influencing House CallsHouse Calls

N=36 N=36 Open-ended questions/answersOpen-ended questions/answers Most frequently cited reasons:Most frequently cited reasons:

– Desire to care for underserved populationDesire to care for underserved population

– Desire for better patient relationshipsDesire for better patient relationships

– Financial and lifestyle issuesFinancial and lifestyle issues

Landers SH et al, Case Management Journals 10 (3), 2009Landers SH et al, Case Management Journals 10 (3), 2009

““It gives you a much better picture of what is going It gives you a much better picture of what is going on with the patient and their family than you can on with the patient and their family than you can get in the office.”get in the office.”

““It gives you a more intimate relationship with It gives you a more intimate relationship with patient and family and they trust you more.”patient and family and they trust you more.”

““Better able to use family to improve life-health of Better able to use family to improve life-health of index patient.” index patient.”

““I saw a glaring deficit in adequate care for elderly I saw a glaring deficit in adequate care for elderly patients.” patients.”

Landers SH et al, Case Management Journals 10 (3), 2009Landers SH et al, Case Management Journals 10 (3), 2009

Conceptual Role of Home Care for Older AdultsConceptual Role of Home Care for Older Adults

TimeTime

FunctionFunction

PreventativePreventative

AcuteAcute

Transitions of CareTransitions of Care

LTCLTC

Home Care ResourcesHome Care Resources

Acute CareAcute Care

SLVHCSSLVHCS Hospital at Home Focus of Hospital at Home Focus of ServiceService

The SLVHCS Hospital at Home program provided key hospital services The SLVHCS Hospital at Home program provided key hospital services within the home setting for those conditions that could safely be within the home setting for those conditions that could safely be provided in the home. It initially was structured as an “early-provided in the home. It initially was structured as an “early-discharge” model (i.e. veterans were discharged “early” from their discharge” model (i.e. veterans were discharged “early” from their traditional hospital stay to Hospital at Home) . traditional hospital stay to Hospital at Home) .

This focus has since expanded, evolving to address the identified This focus has since expanded, evolving to address the identified needs of SVLHCS veterans by providing:needs of SVLHCS veterans by providing:•Early discharge of veterans from the hospital;Early discharge of veterans from the hospital;•Substitution of the traditional hospitalization (i.e. admission occurs Substitution of the traditional hospitalization (i.e. admission occurs from the UCC, ER or clinics without veterans staying in the traditional from the UCC, ER or clinics without veterans staying in the traditional hospital);hospital);•Modified long-term acute care service (“LTAC”) for patients in need Modified long-term acute care service (“LTAC”) for patients in need of longer-term services (e.g. IV medications, for osteomyelitis of longer-term services (e.g. IV medications, for osteomyelitis intensive wound care)intensive wound care)•Preventative approach to minimize hospitalizations and/or ER Preventative approach to minimize hospitalizations and/or ER evaluations for high-risk patients (e.g. patients with high systemic evaluations for high-risk patients (e.g. patients with high systemic utilization in the ER/UCC and/or with frequent hospitalizations)utilization in the ER/UCC and/or with frequent hospitalizations)

SLVHCS Hospital at HomeSLVHCS Hospital at Home

Operational ComponentsOperational Components Initial MD evaluation with daily treatment plan oversight Initial MD evaluation with daily treatment plan oversight Daily skilled RN home evaluationDaily skilled RN home evaluation 24-hour, 7 day a week telephone access to RN and MD24-hour, 7 day a week telephone access to RN and MD Low RN/patientLow RN/patient

Hours: Hours: 7:30 AM – 2 pm (same-day admission). Most admissions occur the 7:30 AM – 2 pm (same-day admission). Most admissions occur the next daynext day

Medical Services:Medical Services: IV medicationsIV medications In-home lab draws and delivery (same day available)In-home lab draws and delivery (same day available) Respiratory servicesRespiratory services HBPC disciplines (Dietician, Rehab, Pharmacy, SW, MH)HBPC disciplines (Dietician, Rehab, Pharmacy, SW, MH)

Target veterans:Target veterans: SLVHCS veterans -- not limited by age – residing within 25 miles of the SLVHCS veterans -- not limited by age – residing within 25 miles of the

NOLA and Slidell clinic sites in need of (1) acute/sub-acute services which NOLA and Slidell clinic sites in need of (1) acute/sub-acute services which can be delivered safely in the home; (2) who are at risk for hospitalizations can be delivered safely in the home; (2) who are at risk for hospitalizations

SLVHCS Hospital at HomeSLVHCS Hospital at HomeOrganizational StructureOrganizational Structure H@H falls within the HBPC umbrella, providing acute/sub-acute H@H falls within the HBPC umbrella, providing acute/sub-acute

services within the established chronic disease model of HBPC. services within the established chronic disease model of HBPC. Dedicated H@H FTE: RNs (including 1 Program Coordinator)Dedicated H@H FTE: RNs (including 1 Program Coordinator)

Complete staff overlap within “chronic” HBPC and H@H, which Complete staff overlap within “chronic” HBPC and H@H, which facilitates seamless transitions of care. The following services facilitates seamless transitions of care. The following services are provided within the home setting: are provided within the home setting: PhysicianPhysician DieticianDietician SWSW MHMH PharmacyPharmacy RehabRehab

Cross-training of all HBPC RNs to H@H care, allowing flexible Cross-training of all HBPC RNs to H@H care, allowing flexible cross-coverage, as needed, to promote optimal resource cross-coverage, as needed, to promote optimal resource utilization. utilization.

SLVHCS Hospital at HomeSLVHCS Hospital at HomeAverage age: 69 (38-94)Average age: 69 (38-94)Since inception: 178 unique Since inception: 178 unique

veterans served with 223 veterans served with 223 admissions (18% readmission rate)admissions (18% readmission rate)

FY10-FY11 : 146 uniquesFY10-FY11 : 146 uniquesAverage # chronic conditions: 8Average # chronic conditions: 8

Most Common Admitting Most Common Admitting DiagnosesDiagnoses

CHF CHF

COPD COPD Cellulitis Cellulitis UTI/urosepsis UTI/urosepsis

DVT/PE DVT/PE

Post-op wound care Post-op wound care

Pneumonia Pneumonia At risk Hyperglycemia At risk Hyperglycemia

At risk HTN At risk HTN

The Partnerships…The Partnerships…The SLVHCS Hospital at Home program The SLVHCS Hospital at Home program works directly with all SLVHCS services. works directly with all SLVHCS services. The general distribution of referrals are The general distribution of referrals are as follows: as follows:

Tulane Inpatient Service Tulane Inpatient Service 51%51% Chronic disease HBPCChronic disease HBPC 25%25% VA Urgent CareVA Urgent Care 14%14% ClinicsClinics 7%7% CommunityCommunity 3%3%

SLVHCS Hospital at HomeSLVHCS Hospital at Home Length of StayLength of Stay

SubstitutiveSubstitutive 6 days6 daysEarly Discharge Early Discharge 7 days7 daysLTAC LTAC 16 days16 daysPreventative Preventative 7 days7 days

SLVHCS H@H Incremental Cost SLVHCS H@H Incremental Cost AnalysisAnalysis

Assumption: annual H@H admission = 100Assumption: annual H@H admission = 100 Revenues Revenues (VERA reimbursement, $22k, 38% eligibility)(VERA reimbursement, $22k, 38% eligibility)

$638k$638k Start-up equip/suppl costs (excluding space)Start-up equip/suppl costs (excluding space) $ 15,000$ 15,000 Annual Expenses:Annual Expenses:

– Personnel (2 RNs, 0.5 MD)Personnel (2 RNs, 0.5 MD) $375,000$375,000– IV infusionIV infusion $ 23,100$ 23,100– Lab draws (Tulane)Lab draws (Tulane) $ 14,000$ 14,000– Cars ($340/month, 3 cars)Cars ($340/month, 3 cars) $ 12,240$ 12,240

Total Expenses (start-up, annual)Total Expenses (start-up, annual) $439k$439k Additional cost savings may occur from hospital avoidance Additional cost savings may occur from hospital avoidance

via the substitutive model: via the substitutive model: $320$320kk

BenefitsBenefits• Veterans are given a greater choice in how and where they Veterans are given a greater choice in how and where they

receive their care; receive their care;

• Improved transitions of careImproved transitions of care

• Broader continuum of services within HBPC, creating a Broader continuum of services within HBPC, creating a potentially new paradigm in the model of home care. potentially new paradigm in the model of home care.

• Encourages collaboration of services and partnerships with Encourages collaboration of services and partnerships with patients/caregivers. patients/caregivers.

• Less fragmentation of health care delivery. Less fragmentation of health care delivery.

• Potential cost savingsPotential cost savings

Conceptual Role of Home Care for Older AdultsConceptual Role of Home Care for Older Adults

TimeTime

FunctionFunction

PreventativePreventative

AcuteAcute

Transitions of CareTransitions of Care

LTCLTC

Home Care ResourcesHome Care Resources

LimitationsLimitations

• 25-mile/30 minute driving limitation25-mile/30 minute driving limitation• Any further geographic expansion will Any further geographic expansion will

lead to greater travel time and less lead to greater travel time and less efficiency of care delivery. efficiency of care delivery.

• Comparative geographic distribution Comparative geographic distribution of SLVHCS veterans suggest greater of SLVHCS veterans suggest greater rural/suburban growth? rural/suburban growth?

Tele- Hospital at Home Tele- Hospital at Home

A remote monitoring component of Hospital at Home, utilizing real-A remote monitoring component of Hospital at Home, utilizing real-time tele-monitoring equipment . time tele-monitoring equipment .

•Potential Benefits:Potential Benefits:– Improved access to care with the potential to expand to a broader Improved access to care with the potential to expand to a broader

geographic region;geographic region;– Greater efficiency of staffing (visits q2-4 days)Greater efficiency of staffing (visits q2-4 days)– Real-time monitoring with capacity to conduct respiratory, cardiac, wound, Real-time monitoring with capacity to conduct respiratory, cardiac, wound,

and abdominal assessments. and abdominal assessments. •Insights gained: Insights gained:

– Quality of the equipment provides a strong adjunctive service. Quality of the equipment provides a strong adjunctive service. – Potential areas of service appear to match major focus of H@H. Potential areas of service appear to match major focus of H@H. – There is need for caregiver present to assist with placement of peripheral There is need for caregiver present to assist with placement of peripheral

devices on the machines (e.g. placemen of the stethoscope to the back). devices on the machines (e.g. placemen of the stethoscope to the back). •HurdlesHurdles

– Reliance on caregiverReliance on caregiver– Equipment transportEquipment transport– Patient acceptance? Patient acceptance?

Lessons LearnedLessons Learned

The success of the SLVHCS Hospital at The success of the SLVHCS Hospital at Home program has occurred through strong Home program has occurred through strong leadership support. leadership support.

As a new innovative program, there is a As a new innovative program, there is a need to market again and again and need to market again and again and again…to each service. again…to each service.

Need for dedicated staff who believe in Need for dedicated staff who believe in what this model of care can providewhat this model of care can provide

Contact InformationContact Information

For questions about this audio conference please For questions about this audio conference please contact Dr. Lumie Kawasaki at contact Dr. Lumie Kawasaki at lumi.kawasaki@va.govlumi.kawasaki@va.gov

For any questions about the monthly GRECC For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328at tim.foley@va.gov or call (734) 222-4328

To evaluate this conference for CE credit please To evaluate this conference for CE credit please obtain a “Satellite Registration” form and a obtain a “Satellite Registration” form and a “Faculty Evaluation” form from the Satellite “Faculty Evaluation” form from the Satellite Coordinator at you facility. The forms must be Coordinator at you facility. The forms must be mailed to EES within 2 weeks of the broadcastmailed to EES within 2 weeks of the broadcast