The Evolution of the SLVCS Hospital at Home Program

1. The Evolution of the SLVCS Hospital at Home Program Lumie Kawasaki, M.D., M.B.A. March 24, 2011

2. Objectives • To provide an understanding of the general Hospital at Home model in the context of other home care models. • To describe the formation and development of the SLVHCS Hospital at Home program • To provide a current snapshot of the SLVHCS H@H program. • To identify benefits, limitations, lessons learned; and • To describe the next phase in development

3. Hospital at Home Model • Arose from a need for alternative models to reduce reliance on inpatient care due to: • excess demand over supply of acute hospital beds, • growing health care technology, • greater emphasis on cost-containment measures • inpatient care may not always produce optimal clinical outcomes for some groups of patients – particularly the elderly.

4. Background • Hospital at Home is an alternative model to inpatient care • International model • Types: “early-discharge” “substitution” • Meta-analysis • improved patient satisfaction • clinical outcomes with traditional hospitalization • Johns Hopkins/Bruce Leff, MD • Portland VAMC/Scott Mader, MD • Hawaii VAMC

5. Background The post-Katrina environment had: • Reduced hospital bed capacity and crowded ERs due to multiple hospital closures, including the SLVHCS-based Inpatient Services. • Greater reliance on local non-VA hospitals (33), and other VA hospitals within VISN 16, leading to fragmented care, redundant diagnostic studies. • Highlighted the vulnerabilities of older adults with higher mortality and depression post-Katrina. • Exponential growth in the SLVHCS veteran population (151%) as veterans returned “home SLVHCS Hospital at Home opened October 1, 2007 to help address some of these needs…

6. The Concept of Home • Physical Structure • Territory • Locus in space • Self and self-identity • Social and cultural unit • Familiar • Center • Protector • Healer

8. “The image of a physician delivering care to a sick patient at home is one of the essential and enduring images in the collective consciousness of medicine. It is an image that no doubt once inspired, and perhaps still inspires, some to pursue a career in medicine. It is an image from which the medical profession, as a whole, once drew inspiration so as to say “Yes, this is what physicians are about. Physicians take care of patients.” Leff, B. “The Future History of Home Care and Physician House Calls in the United States,” 2001

9. Uniqueness of Home Visits • Qualitative interview study performed, as part of a large randomized psychosocial intervention study on the effects of home visit to Danish patients with colorectal cancer. N=21 informants. • “Healthcare interventions in patients’ homes result in a well-balanced contact between the professional visitor and the patient by overcoming the barrier felt by patients in the hospital setting, where they are sometimes treated as objects. Meeting patients in their home setting gave the visitor a deeper understanding of them as persons and facilitated dialogue about their daily lives, problems, social network, and social resources.” Ross, L, et al. Cancer Nursing. 2002 Improved balance of power

10. Uniqueness of Home Visits Understanding the client’s health need as he or she sees it • N=200 • Prospective, repeated-measures design study, focusing on patient safety and caregiver issues. • Compared the yield of a clinic-based home assessment with the yield of a home visit involving patients with dementia. • 84% of serious problems were identified only at home visit, not at clinic visit. Issues: social isolation, caregiver stress, fall risk. Ra,sde;;. KW. et al, Alzheimer Dis Assoc Disord, 2004

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

12. Uniqueness of Home Care • Equal balance of power • Understanding of patient’s health needs as he or she sees it • Community connections • Social model -- • Improved understanding of physiological/psychological aspects of one’s disease • Improved coping • Enhanced social supports and contacts • Improved knowledge of community resources • Broader understanding of patient on part of the health professional

13. Home Care Models • Preventive • Transitions of care • Primary Care/Long-term • Acute Care Model

14. Preventive Care • Meta-analysis, 15 studies • 9 studies to general elderly population • 6 studies to older adults at risk for adverse events • Significant impact on mortality, admissions to long-term care institutions. Elkan R, et al. BMJ 2001 • 3-year RCT, N=215, 75+yo, Geriatric APN in collaboration with geriatrician. Annual CGA with quarterly follow-up. • Significant impact on disability (ADLs) and permanent nursing home stays. Stuck A et al. NEJM 1994 • 3-year stratified randomized trial, 75+yo, RN in collaboration with geriatrician. Annual CGA with quarterly follow-up. • Reduce risk for elderly at low risk, but not at high risk for functional impairment. Stuck A et al. Arch Int Med 2000

15. Transitional Care • Care Transition Coaching • APN “transition coach,” begin in hospital and 30-day post-discharge • 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. • Lower all-cause re-hospitalization rate at 30 and 90 days reduced. Lower costs. (Coleman et al, Arch Int Med, 2006) • APN transitional care model • APN-directed, begin in hospital, arranges post-discharge plans. 7-day per week telephone access. • 3 RCTs: greater pt satisfaction, lower readmissions, decreased costs. • CHF/Disease Management • 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 years. • Reduced all-cause mortality, longer survival, longer event-free survival, fewer unplanned readmissions, shorter hospital stay if admitted, fewer ICU admissions. (Ahern MM et al, Disease Management, 2007; Simon S et al, Circulation, 2002)

16. Primary/Long-Term Care • VA- Home-Based Primary Care • Physician Home Visiting Program

17. VA Home-Based Primary Care

18. Clinician Rankings of Factors Influencing House Calls • N=36 • 10-point scale reflecting weight of influence • Motivators: • Improved patient care • Autonomy • Positive experience with house call • Barriers: • Lack of training regarding house calls • Inconvenient • Inadequate compensation Landers SH et al, Case Management Journals 10 (3), 2009

19. Clinician Rankings of Factors Influencing House Calls • N=36 • Open-ended questions/answers • Most frequently cited reasons: • Desire to care for underserved population • Desire for better patient relationships • Financial and lifestyle issues Landers SH et al, Case Management Journals 10 (3), 2009

20. “It gives you a much better picture of what is going on with the patient and their family than you can get in the office.” “It gives you a more intimate relationship with patient and family and they trust you more.” “Better able to use family to improve life-health of index patient.” “I saw a glaring deficit in adequate care for elderly patients.” Landers SH et al, Case Management Journals 10 (3), 2009

21. Conceptual Role of Home Care for Older Adults Home Care Resources Preventative Acute Transitions of Care Function LTC Time

22. Acute Care

23. SLVHCS Hospital at Home Focus of Service The SLVHCS Hospital at Home program provided key hospital services within the home setting for those conditions that could safely be provided in the home. It initially was structured as an “early-discharge” model (i.e. veterans were discharged “early” from their traditional hospital stay to Hospital at Home) . This focus has since expanded, evolving to address the identified needs of SVLHCS veterans by providing: • Early discharge of veterans from the hospital; • Substitution of the traditional hospitalization (i.e. admission occurs from the UCC, ER or clinics without veterans staying in the traditional hospital); • Modified long-term acute care service (“LTAC”) for patients in need of longer-term services (e.g. IV medications, for osteomyelitis intensive wound care) • Preventative approach to minimize hospitalizations and/or ER evaluations for high-risk patients (e.g. patients with high systemic utilization in the ER/UCC and/or with frequent hospitalizations)

24. SLVHCS Hospital at Home • Operational Components • Initial MD evaluation with daily treatment plan oversight • Daily skilled RN home evaluation • 24-hour, 7 day a week telephone access to RN and MD • Low RN/patient • Hours: 7:30 AM – 2 pm (same-day admission). Most admissions occur the next day • Medical Services: • IV medications • In-home lab draws and delivery (same day available) • Respiratory services • HBPC disciplines (Dietician, Rehab, Pharmacy, SW, MH) • Target veterans: • 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 can be delivered safely in the home; (2) who are at risk for hospitalizations

25. SLVHCS Hospital at Home Organizational Structure • H@H falls within the HBPC umbrella, providing acute/sub-acute services within the established chronic disease model of HBPC. • Dedicated H@H FTE: RNs (including 1 Program Coordinator) • Complete staff overlap within “chronic” HBPC and H@H, which facilitates seamless transitions of care. The following services are provided within the home setting: • Physician • Dietician • SW • MH • Pharmacy • Rehab • Cross-training of all HBPC RNs to H@H care, allowing flexible cross-coverage, as needed, to promote optimal resource utilization.

26. SLVHCS Hospital at Home • Average age: 69 (38-94) • Since inception: 178 unique veterans served with 223 admissions (18% readmission rate) • FY10-FY11 : 146 uniques • Average # chronic conditions: 8

27. Most Common Admitting Diagnoses CHF COPD Cellulitis UTI/urosepsis DVT/PE Post-op wound care Pneumonia At risk Hyperglycemia At risk HTN

28. The Partnerships… The SLVHCS Hospital at Home program works directly with all SLVHCS services. The general distribution of referrals are as follows: • Tulane Inpatient Service 51% • Chronic disease HBPC 25% • VA Urgent Care 14% • Clinics 7% • Community 3%

29. SLVHCS Hospital at HomeLength of Stay • Substitutive 6 days • Early Discharge 7 days • LTAC 16 days • Preventative 7 days

30. SLVHCS H@H Incremental Cost Analysis • Assumption: annual H@H admission = 100 • Revenues (VERA reimbursement, $22k, 38% eligibility) $638k • Start-up equip/suppl costs (excluding space) $ 15,000 • Annual Expenses: • Personnel (2 RNs, 0.5 MD) $375,000 • IV infusion $ 23,100 • Lab draws (Tulane) $ 14,000 • Cars ($340/month, 3 cars) $ 12,240 • Total Expenses (start-up, annual) $439k • Additional cost savings may occur from hospital avoidance via the substitutive model: $320k

31. Benefits • Veterans are given a greater choice in how and where they receive their care; • Improved transitions of care • Broader continuum of services within HBPC, creating a potentially new paradigm in the model of home care. • Encourages collaboration of services and partnerships with patients/caregivers. • Less fragmentation of health care delivery. • Potential cost savings

32. Conceptual Role of Home Care for Older Adults Home Care Resources Preventative Acute Transitions of Care Function LTC Time

33. Limitations • 25-mile/30 minute driving limitation • Any further geographic expansion will lead to greater travel time and less efficiency of care delivery. • Comparative geographic distribution of SLVHCS veterans suggest greater rural/suburban growth?

34. Tele- Hospital at Home A remote monitoring component of Hospital at Home, utilizing real-time tele-monitoring equipment . • Potential Benefits: • Improved access to care with the potential to expand to a broader geographic region; • Greater efficiency of staffing (visits q2-4 days) • Real-time monitoring with capacity to conduct respiratory, cardiac, wound, and abdominal assessments. • Insights gained: • Quality of the equipment provides a strong adjunctive service. • Potential areas of service appear to match major focus of H@H. • 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). • Hurdles • Reliance on caregiver • Equipment transport • Patient acceptance?

35. Lessons Learned • The success of the SLVHCS Hospital at Home program has occurred through strong leadership support. • As a new innovative program, there is a need to market again and again and again…to each service. • Need for dedicated staff who believe in what this model of care can provide

36. Contact Information • For questions about this audio conference please contact Dr. Lumie Kawasaki at lumi.kawasaki@va.gov • For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328 • To evaluate this conference for CE credit please obtain a “Satellite Registration” form and a “Faculty Evaluation” form from the Satellite Coordinator at you facility. The forms must be mailed to EES within 2 weeks of the broadcast