the importance of home-based primary care: why older adults need it bruce leff, md professor of...
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The Importance of Home-based Primary Care: Why Older Adults Need It
Bruce Leff, MDProfessor of Medicine
Co-Director, Elder House Call ProgramJohns Hopkins University School of Medicine
Campaign for Better Care WebinarJune 30, 2010
Let’s Start with Leo
• Frail, homebound, 89 years old• Limited mobility; walks with walker• Needs help with activities of daily living• Heart failure, lung disease, arthritis,
diabetes, hypertension, etc• Admitted 4 times to the hospital last
year for heart failure• Many medicines prescribed by
physicians who have not seen him in years
• Lives with frail wife who is his caregiver
The Population is Aging and Increasingly Frail
% of Older Adults Who Need Daily Personal Care
• There are ~ 2-3 million older adults with high grade functional impairment
• Will double in about 15 years
Our Current System Doesn’t Meet Leo’s Needs
• He can’t get to the office• Uses 911 as primary care, goes to the
emergency department and is admitted to the hospital repeatedly
• Treated as a basket of chronic conditions rather than a person with chronic conditions
• No continuity of care• No attention to his quality of life
Chronic Conditions and Medicare Expenditures
Number of Chronic Conditions
Percent of Beneficiaries 65+
Percent Medicare Expenditures
0 18 1
1 19 4
2 21 11
3 18 18
4 12 21
5 7 18
6 3 13
7+ 2 14
22% 66%
1. Compassionate, mobile primary care team providing primary and acute care
2. Target the most ill older adults, focus on providing high quality geriatric care and preventing hospitalizations
3. State-of-the-art diagnosis and treatment in the home
4. Coordinate ALL medical and social services
5. Financially viable for providers and for society
Key Principles of Effective Home-Based Primary Care Practices
Key Elements of the Home-Based Primary Care Model
SubspecialistsRadiology
Acute, ER, Ambulance
Aides, Food, Environment, Legal Counsel,
Housing
Rehab, HHA, Hospice
Pharmacy, Durable Medical Equipment, IV,
Oxygen
Transportation, Labs
PatientMD/NP/SW24/7 Team
Portable HER
Additional Advantages of Home-based Primary Care
• Provides access to health care and focuses on unique needs of older adults
• “High touch, high tech” - portable technology expands clinical repertoire of home based physician compared to clinic
• Seeing the patient in his / her own environment - builds trust, improves diagnosis, develop better care plans
• House call physicians coordinate services and care better
• Better integration of caregivers into care plans
Outcomes of Home-Based Primary CareProgram Outcome
Veterans Affairs Home-Based Primary Care ↓ Total health care costs 24%Highest pt satisfaction any VA program -83%
Virginia Commonwealth University ↓ Hospital costs 60%
Urban Medical Housecalls, Boston ↓ Hospital admissions 29%↓ Hospital days 34%
University of Pennsylvania ↓ Total health care costs 50% ↓ Hospitalizations 64%
Philadelphia House Call Program for post-hospital patients
↓ Hospital readmissions 50%↓ Total health care costs $3,000 to $4,845 per pt
Elder Partnership for All Inclusive Care (ElderPAC) at Penn
↓ Medicare hospital days 59%↓ Medicare care costs 50%
Office Without Walls, Nevada ↓ Hospitalizations 27%↓ Costs by $760 per patient
Indianapolis House Call program ↓ Hospitalization 44% for high risk patients with multiple chronic diseases