Home Based Primary Care: An Interdisciplinary Model of Care in the Department of Veterans Affairs

1. Session #E5a October 18, 2014 Home Based Primary Care: An Interdisciplinary Model of Care in the Department of Veterans Affairs Mandy McCorkindale, PsyD Clinical Psychologist, Home Based Primary Care Julie Ruple, PharmD, CGP Clinical Pharmacist, Home Based Primary Care Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • We have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the need for cost-effective, patient and family centered Home-Based Primary Care (HBPC) services for the geriatric population. • Describe an integrated, primary care model for in-home care involving team members from a wide range of disciplines. • Discuss the roles of the psychologist and pharmacist in promoting a whole-person approach to the management of patients with complicated medical/mental health problems. • Describe the application of an HBPC program in a rural area, including unique challenges to in-home care, barriers to effective implementation, as well as patient and team successes.

4. What is Home Based Primary Care? “Home Based Primary Care is health care services provided to Veterans in their home. A VA physician supervises the health care team who provides the services. Home Based Primary Care is for Veterans who have complex health care needs for whom routine clinic-based care is not effective.” U.S. Department of Veterans Affairs http://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp#

5. Goals for HBPC Promotinghealth and independence Reducingthe need for hospitalization, nursing home care, ER visits, and outpatient clinic visits Assisting by adapting the home for a safe and therapeutic environment, arranging supportive services, and providing patient and caregiver education Supportingthe caregiver in the care of the veteran (Beales & Edes, 2009)

6. Goals for HBPC Meetingthe changing needs of the veteran and family Enhancingthe veteran’s quality of life through symptom management and other comfort measures Allowingthe veteran the option of dying at home rather than in an institution Helpingthe veteran & family cope with chronic disease Providingan academic and clinical setting for training (Beales & Edes, 2009)

7. Population Served • Complex, chronic, disabling disease • Disease prevalence • Demographics / clinical characteristics • 47 percent of pts are dependent in 2 or more ADLs • Routine, clinic based care is no longer effective • Inclusion criteria for CAVHS (Edes, 2010)

8. Rationale for Cost (Edes, 2010) (North, Kehm, Bent, & Hartman, 2008)

9. The TEAM!! Admin & Support Staff Chaplain Other Home Care Services Medical Foster Home

10. PHYSICIAN • Supervise overall patient care • May admit patients or make home visits • Integral part of Treatment Plan development and monitoring

11. APRN • Assesses patient medical needs in home • Primary medical management responsibility • Serves as a case manager to coordinate care among the team members and specialties

12. RN • Assesses patient’s needs in the home • Fill mediplanners when appropriate • Telephone triage on weekends

13. Social Worker • Maximize benefits (VA and nonVA) • Assesses veteran’s relationships • Education for advance directives and DNR • Ongoing assessment of appropriateness for HBPC program

14. Dietitian • Ongoing assessment of nutritional status • Recommends nutritional adjustments in management of chronic conditions • Dietary guidance for current condition or prevention of exacerbations

15. Rehabilitation Therapist • Ongoing assessment of functional status • Home evaluation for structural modifications • Determines need for medical equipment • Establishes a therapeutic program to maximize functional independence

16. Pharmacist

17. Pharmacist • Function under Scope of Practice • Medication education (interprofessional, patients, and students) • Quality Assurance

18. Pharmacist • Pharmaceutical Assessments: • Eliminate polypharmacy • Fall prevention • Identifying high risk or potentially inappropriate meds for the elderly • Lab monitoring • Interactions (drug, food, herbal, disease state) • Renal & hepatic dose adjustment • Antibiotic selection

19. Psychologist Why do we need a psychologist?? • 44% depression; 29% substance abuse; 24% anxiety or PDs; 21% PTSD; 20% schizophrenia; half of those over the age of 85 have dementia Position Description: • Evaluation, diagnosis, and treatment of mental disorders • Assessment of cognitive deficits and functional capacities • Prevention services • Services for family caregivers, and couples/families • Behavioral medicine interventions • Communication/interaction among team members • Supervision/training (Karel & Karlin, 2012)

20. Psychologist Top Ten themes of what we do: • Educating team members on behavioral health issues and family dynamics • Increasing veteran access to mental health services • Helping team to develop strategies for working with veterans/families • Enhancing overall program quality/quality of care • Increasing holistic conceptualization/approach to patient care • Helping veterans and families to cope better • Supporting team development and cohesion • Contributing to team treatment planning and meetings • Being available for staff consultation and support (Karel & Karlin, 2012)

21. The EffectiveInterprofessional Team • Relationship development over time • Understanding / respecting all roles • Complementary skills • Committed to a common goal • Ongoing communication plan (Sargeant, Loney, & Murphy, 2008)

22. Challenges • Geographically challenging • Changing the perception of services provided • Establishing boundaries • Patient goals: aggressive vs comfort • Caregiver frailty

23. Success • Improved transitions of care/referrals • Improved medication mgmt and adherence • Cost savings and better resource distribution • Team members: “our work has meaning” • Teaching site for interdisciplinary model • Achievement of our own “Service” = improved team connection and access to recognition • Improved quality of life (Hughes et al., 2000)

24. Central Arkansas VA: Home Based Primary Care “Practitioner Nurse Rebecca Johnson: Dearest Home Health Team of the VA: It was a real pleasure to have such a wonderful staff to attend to my husband. As far as I am concerned, you all are the best. You and the staff showed the ultimate concern for him. You and the staff always would take time and ask him questions about how he felt and what you could do to help him. Thank you so much for being available for us. Mrs. Johnson, thank you for your training and trust in me. Each of you are very special to me. You always brought cheer into our home every time you came. Thank you for your words of sympathy. You know how much I will miss him, but the Lord will help me to endure. Thanks to all of you!”

25. Central Arkansas VA: Home Based Primary Care Questions?? amanda.mccorkindale@va.gov julie.ruple@va.gov

26. Bibliography Beales, J. & Edes, T. (2009). Veteran’s affairs home based primary care. Clinics in Geriatric Medicine (25), 149-154. Desai, N., Smith, K., & Boal, J. (2008). The positive financial contribution of home- based primary care programs: the case of the mount sinai visiting doctor. Journal of American Geriatric Society (56) 4, 744-749. Edes, T. (2010). Innovations in homecare: va home-based primary care. American Society on Aging (34)2, 29-34. Home Health Care Service Policy Memorandum No. HC-00C (June 24, 2014). Home health care service definition, objectives, and types of patients. Little Rock, AR. Home Health Care Service Policy Memorandum No. HC-01 (June 17, 2014). Home based primary care mission, scope of care, and services. Little Rock, AR. Home Health Care Service Policy Memorandum No. HC-08 (June 16, 2014). Admission to the HBPC program. Little Rock, AR.

27. Bibliography Hughes, S., Weaver, F., Giobbie-Hurder, A., Manheim, L., Henderson, W., Kubal, J.,…Cummings, J. (2000). Effectiveness of team-managed home-based primary care: a randomized multicenter trial. Journal of American Medical Association (284) 22, 2877-2885. Karel, M. & Karlin, B. (2012). The VA HBPC mental health initiative: program implementation and preliminary outcomes. Gerontological Society of America Meeting. San Diego, CA. North, L., Kehm, L., Bent, K., & Hartman, T. (2008). Can home-based primary care cut costs? The Nurse Practitioner (33) 7, 39-44. Sargeant, J., Loney, E., & Murphy, G. (2008). Effective interprofessional teams: “contact is not enough” to build a team. Journal of Continuing Education of Health Professions Fall;28(4): 228-34. US Department of Veterans Affairs. Information about home-based primary care. http://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp

28. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!