Continuity of care and health care cost among community-dwelling older adult veterans living with dementia

OBJECTIVES

To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia.

DATA SOURCES

Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015.

STUDY DESIGN

FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.

DATA COLLECTION

Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).

PRINCIPAL FINDINGS

Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost.

CONCLUSIONS

COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.

A qualitative study of health-care experiences and challenges faced by ageing homebound adults

BACKGROUND

The ageing of the global population is associated with an increasing prevalence of chronic diseases and functional impairments, resulting in a greater proportion of homebound individuals.

OBJECTIVE

To examine the health-care experiences of older homebound adults who have not previously received home-based primary care (HBPC). To explore their impressions of this method of care.

DESIGN

Cross-sectional qualitative study using semi-structured interviews.

SETTING AND PARTICIPANTS

18 older homebound individuals in Central Virginia.

RESULTS

Our findings revealed that homebound individuals faced significant health challenges, including pain resulting from various comorbidities. They felt that their mobility was restricted by their physical conditions and transportation challenges. These were major barriers to social outings and health-care access. Participants left their homes infrequently and typically with assistance. Regarding office-based care, participants were concerned about long wait times and making timely appointments. Some thought that HBPC would be convenient and could result in better quality care; however, others believed that the structure of the health-care system and its focus on efficiency would not permit routine HBPC.

DISCUSSION AND CONCLUSIONS

Older homebound adults in this study faced high burdens of disease, a lack of mobility and difficulty accessing quality health care. Our observations may help researchers and clinicians better understand the health-care experiences and personal opinions of older homebound individuals, informing the development of effective and empathetic home-based care. Participant responses illuminated a need for education about HBPC. We must improve health-care delivery and develop comprehensive, patient-centered HBPC to meet the needs of homebound individuals.

The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review

Background

With the shortage of primary care providers to provide home-based care to the growing number of homebound older adults in the U.S. Nurse Practitioners (NPs) are increasingly utilized to meet the growing demand for home-based care and are now the largest type of primary care providers delivering home-visits.

Purpose

The purpose of this study was to systematically examine the current state of the evidence on health and healthcare utilization outcomes associated with NP-home visits.

Method

Five Databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library) were systematically searched to identify studies examining NP-home visits. The search focused on English language studies that were published before April 2019 and sought to describe the outcomes associated with NP-home visits. We included experimental and observational studies.  Quality appraisal was performed with the Kmet, Lee & Cook tool, and results summarized qualitatively. The impact of NP-home visits on clinical (functional status, quality of life [QOL]), and healthcare utilization (hospitalization, Emergency department(ED) visits) outcomes was evaluated.

Results/Discussion

A total of 566 citations were identified; 7 met eligibility criteria and were included in the review. The most commonly reported outcomes were emergency department (ED) visits and readmissions. Given the limited number of articles generated by our search and wide variation in intervention and outcomes measures. NP-home visits were associated with reductions in ED visits in 2 out of 3 studies and with reduction in readmissions in 2 out of 4 studies.

Conclusion

Published studies evaluating the outcomes associated with NP-home visits are limited and of mixed quality. Limitations include small sample size, and variation in duration and frequency of NP-home visits. Future studies should investigate the independent effect of NP-home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.

Measuring Frailty in Health Care Databases for Clinical Care and Research

Considering the increasing burden and serious consequences of frailty in aging populations, there is increasing interest in measuring frailty in health care databases for clinical care and research. This review synthesizes the latest research on the development and application of 21 frailty measures for health care databases. Frailty measures varied widely in terms of target population (16 ambulatory, 1 long-term care, and 4 inpatient), data source (16 claims-based and 5 electronic health records [EHR]-based measures), assessment period (6 months to 36 months), data types (diagnosis codes required for 17 measures, health service codes for 7 measures, pharmacy data for 4 measures, and other information for 9 measures), and outcomes for validation (clinical frailty for 7 measures, disability for 7 measures, and mortality for 16 measures). These frailty measures may be useful to facilitate frailty screening in clinical care and quantify frailty for large database research in which clinical assessment is not feasible.

Connecting Social, Clinical, and Home Care Services for Persons with Serious Illness in the Community

The medical, psychological, cognitive, and social needs of older adults with serious illness are best met by coordinated and team-based services and support. These services are best provided in a seamless care model anchored by integrated biopsychosocial assessments focused on what matters to older adults and their social determinants of health; individualized care plans with shared goals; care provision and management; and quality measurement with continuous improvement. This model requires (1) racially and ethnically diverse healthcare professionals, including mental health and direct service workers, with training in aging and team collaboration; (2) an integrated network of community-based organizations (CBOs) providing in-home services; (3) an electronic communication platform that spans the system of providers and organizations with skilled technology staff; and (4) payment models that incentivize team-based care across the continuum of services, including CBOs, with adequate salaries and academic loan forgiveness to recruit and retain high-quality team members. Assuring that this model is effective requires ongoing quality assurance measures that include not only quality of care and utilization data to demonstrate cost offsets of service integration, but also quality of life for both the older adults and the family members caring for them. Although this may seem a lofty ideal in comparison with our current fragmented system, we review models that provide the key elements effectively and cost efficiently. We then propose an Essential Care Model that defines best practice in meeting the needs of older adults with serious illness and their families. J Am Geriatr Soc 67:S412-S418, 2019.

Dedicated to the Mission: Strategies US Department of Veterans Affairs Home-Based Primary Care Teams Apply to Keep Veterans at Home

BACKGROUND/OBJECTIVES

The US Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) Program provides interdisciplinary, long-term primary care for frail, disabled, or chronically ill veterans. This research identifies strategies used by HBPC teams to support veterans in their homes, rather than in institutionalized care.

DESIGN

Focus groups and semistructured interviews were conducted with HBPC interdisciplinary team (IDT) members, including program directors, medical directors, and key staff, from September 2017 to March 2018. Field observations were gathered during visits to veterans' homes and IDT meetings.

SETTING

In-person site visits were conducted at eight HBPC Programs across the United States. Sites varied in location, setting, and primary care model.

PARTICIPANTS

A total of 105 HBPC professionals.

MEASUREMENT

Qualitative thematic content analysis.

RESULTS

Four main strategies drive and support the shared mission of IDTs to support veterans at home: fostering frequent communication among IDT members, veterans, caregivers, and outside agencies; development of longitudinal, trusting, reliable relationships within IDTs and with veterans and caregivers; ongoing, consistent education for IDT members and veterans and caregivers; and collaboration within and outside IDTs. Adhering to this mission meant providing timely and efficient care that kept veterans in their homes and minimized the need for acute hospitalizations and nursing home placement.

CONCLUSION

HBPC IDTs studied worked together across disciplines to effectively create a dedicated culture of caring for veterans, caregivers, and themselves, leading to keeping veterans at home. Focusing on the strategies identified in this research may be useful to achieve similar positive outcomes when caring for medically complex, homebound patients within and outside the VA. J Am Geriatr Soc 67:2511-2518, 2019.

Implementing Geographic Information Systems (GIS) into VHA Home Based Primary Care

The Veteran's Health Administration (VHA) Home Based Primary Care (HBPC) program provides comprehensive in-home primary care services to elderly Veterans with complex chronic medical conditions. Nurses have prominent roles in HBPC including as program leaders, primary care providers and nurses who make home visits. Delivery of primary care services to patients in their homes can be challenging due to travel distances, difficult terrain, traffic, and adverse weather. Mapmaking with geographic information systems (GIS) can support optimization of resource utilization, travel efficiency, program capacity, and management during normal operations, and patient safety during disasters. This paper reports on the feasibility, acceptability and outcomes of an initiative to implement GIS mapmaking in VHA HBPC programs. A mixed method evaluation assessed extent of adoption and identified facilitators and barriers to uptake. Results indicate that GIS mapping in VHA HBPC is feasible and can increase effectiveness and efficiency of VHA HBPC nurses.

Measuring Frailty in Medicare Data: Development and Validation of a Claims-Based Frailty Index

Background

Frailty is a key determinant of health status and outcomes of health care interventions in older adults that is not readily measured in Medicare data. This study aimed to develop and validate a claims-based frailty index (CFI).

Methods

We used data from Medicare Current Beneficiary Survey 2006 (development sample: n = 5,593) and 2011 (validation sample: n = 4,424). A CFI was developed using the 2006 claims data to approximate a survey-based frailty index (SFI) calculated from the 2006 survey data as a reference standard. We compared CFI to combined comorbidity index (CCI) in the ability to predict death, disability, recurrent falls, and health care utilization in 2007. As validation, we calculated a CFI using the 2011 claims data to predict these outcomes in 2012.

Results

The CFI was correlated with SFI (correlation coefficient: 0.60). In the development sample, CFI was similar to CCI in predicting mortality (C statistic: 0.77 vs. 0.78), but better than CCI for disability, mobility impairment, and recurrent falls (C statistic: 0.62-0.66 vs. 0.56-0.60). Although both indices similarly explained the variation in hospital days, CFI outperformed CCI in explaining the variation in skilled nursing facility days. Adding CFI to age, sex, and CCI improved prediction. In the validation sample, CFI and CCI performed similarly for mortality (C statistic: 0.71 vs. 0.72). Other results were comparable to those from the development sample.

Conclusion

A novel frailty index can measure the risk for adverse health outcomes that is not otherwise quantified using demographic characteristics and traditional comorbidity measures in Medicare data.

House Calls Are Reaching the Tipping Point - Now We Need the Workforce

Home-based primary care (HBPC) improves the lives of high-cost, frail, homebound patients and their caregivers while reducing costs by keeping patients at home and reducing the use of hospitals and nursing homes. Several forces are behind the resurgence of HBPC, including the rapidly aging population, advancements in portable medical technology, evidence showing the value of HBPC, and improved payments for HBPC. There are 2 million to 4 million patients who could benefit from HBPC, but only 12% are receiving it. The number of these patients is expected to double over the next two decades. This requires a larger and better prepared HBPC workforce, making St. Clair and colleagues' article published within this same issue very timely. They showed residents exposed to HBPC had increased interests in providing HBPC in the future. They also found HBPC training fulfilled all 6 Accreditation Council of Graduate Medical Education core competencies and at least 16 of the 22 Family Medicine Milestone Project subcompetencies. Such medical education curricula are necessary to sufficiently develop a future workforce capable of appropriately providing HBPC to an increasing number of patients.

Care Team Perspectives and Acceptance of Telehealth in Scaling a Home-Based Primary Care Program: Qualitative Study

Background

Novel and sustainable approaches to optimizing home-based primary care (HBPC) programs are needed to meet the medical needs of a growing number of homebound older adults in the United States. Telehealth may be a viable option for scaling HBPC programs.

Objective

The purpose of this qualitative study was to gain insight into the perspectives of HBPC staff regarding adopting telehealth technology to increase the reach of HBPC to more homebound patients.

Methods

We collected qualitative data from HBPC staff (ie, physicians, registered nurses, nurse practitioners, care managers, social workers, and medical coordinators) at a practice in the New York metropolitan area through 16 semistructured interviews and three focus groups. Data were analyzed thematically using the template analysis approach with Self-Determination Theory concepts (ie, relatedness, competence, and autonomy) as an analytical lens.

Results

Four broad themes—pros and cons of scaling, technology impact on staff autonomy, technology impact on competence in providing care, and technology impact on the patient-caregiver-provider relationship—and multiple second-level themes emerged from the analysis. Staff acknowledged the need to scale the program without diminishing effective patient-centered care. Participants perceived alerts generated from patients and caregivers using telehealth as potentially increasing burden and necessitating a rapid response from an already busy staff while increasing ambiguity. However, they also noted that telehealth could increase efficiency and enable more informed care provision. Telehealth could enhance the patient-provider relationship by enabling caregivers to be an integral part of the patient’s care team. Staff members raised the concern that patients or caregivers might unnecessarily overutilize the technology, and that some home visits are more appropriate in person rather than via telehealth.

Conclusions

These findings suggest the importance of considering the perspectives of medical professionals regarding telehealth adoption. A proactive approach exploring the benefits and concerns professionals perceive in the adoption of health technology within the HBPC program will hopefully facilitate the optimal integration of telehealth innovations.

Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs

OBJECTIVES

To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI).

DESIGN

Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks.

SETTING

Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC.

PARTICIPANTS

HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC.

INTERVENTION

HBPC integrated with LTSS under IAH demonstration incentives.

MEASUREMENTS

Measurements include LTI rate and mortality rates, community survival, and LTSS costs.

RESULTS

The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS.

CONCLUSION

HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.

Care Coordination Models Improve Quality of Care for Adults Aging With Intellectual and Developmental Disabilities

A significant gap remains between existing evidence-based care coordination techniques for the general population and those that have been successfully translated for people with intellectual and developmental disabilities (IDD). Two models funded through the Health Care Innovation Awards have dedicated resources to the translation of evidence-based practices in community or clinical settings. This study analyzes quasi-experimental mixed-methods evaluation data, including Medicaid/Medicare claims on more than 600 beneficiaries who participated in the two models and survey data, site visits, and focus groups with participants and caregivers. Qualitative data suggest that both models address key contextual factors, considering residential setting, health disparities, and heterogeneity of the population. We identify key improvements in health care quality related to timeliness, patient safety, and medication reconciliation. In addition, both models show some evidence of reduced claims utilization. This study represents the first step to understand the potential of care coordination to improve the lives of adults aging with IDD. As health systems continue to struggle to manage the cost of their most expensive users and deliver high quality care, these models hold promise as vehicles to reduce utilization and cost among adults who have lived long-term with disability by addressing their unique health care and social needs.

Characteristics of the modern-day physician house call

Many barriers to primary healthcare accessibility in the United States exist including an increased opportunity cost associated with seeking primary care. New models of healthcare delivery aimed at addressing these problems are emerging. The potential impact that on-demand primary care physician house calls services can have on healthcare accessibility, patient care, and satisfaction by both patients and physicians is poorly characterized.We performed a retrospective observational analysis on data from 13,849 patients who utilized Heal, Inc, an application (app)-based, on-demand house calls platform between August 2016 and July 2017. We assessed house call wait time and visit duration, diagnoses by International Classification of Diseases, tenth revision, Inc (ICD10) codes, and house call outcomes by post-visit prescription and lab requests, and patient satisfaction survey.Patients who utilized this physician house call service had a bimodal age distribution peaking at age 1 year and 36 years. Same day acute sick exams (93.9% of pediatric (Ped) and 66.9% of adult requests) for fever and/or acute upper respiratory infection represented the most common use. The mean wait time for as soon as possible house calls were 96.1 minutes, with an overall mean house call duration of 27.1 minutes. A house call was primarily chosen over an Urgent Care Clinic or Doctor's office (46.2% and 41.6% of respondents, respectively), due to convenience or fastest appointment available (69.6% and 33.8% of respondents, respectively). Most survey respondents (94.2%) would schedule house calls again.On-demand physician house calls programs can expand access options to primary healthcare, primarily used by younger individuals with acute illness and preference for a smartphone app-based home visit.

Stressors Facing Home-Based Primary Care Providers

The numbers of homebound patients in the United States are increasing. Home-based primary care (HBPC) is an effective model of interdisciplinary care that has been shown to have high patient satisfaction rates and excellent clinical outcomes. However, there are few clinicians that practice HBPC and clinicians that do face additional stressors. This study sought to better understand the stressors that HBPC providers face in caring for homebound patients. This was a cross-sectional qualitative survey and analysis of HBPC providers. Responses were categorized into four themes: The patient in the home setting, caregiver support, logistics, and administrative concerns. This research is the first to analyze the stressors that providers of HBPC face in serving the needs of complex homebound patients. Awareness and attention to these issues will be important for the future sustainability of home-based primary care.

Validation of the JEN frailty index in the National Long-Term Care Survey community population: identifying functionally impaired older adults from claims data

Background

Use of a claims-based index to identify persons with physical function impairment and at risk for long-term institutionalization would facilitate population health and comparative effectiveness research. The JEN Frailty Index [JFI] is comprised of diagnosis domains representing impairments and multimorbid clusters with high long-term institutionalization [LTI] risk. We test the index’s discrimination of activities-of-daily-living [ADL] dependency and 1-year LTI and mortality in a nationally representative sample of over 12,000 Medicare beneficiaries, and compare long-term community survival stratified by ADL and JFI.

Methods

2004 U.S. National Long-Term Care Survey data were linked to Medicare, Minimum Data Set, Veterans Health Administration files and vital statistics. ADL dependencies, JFI score, age and sex were measured at baseline survey. ADL and JFI groups were cross-tabulated generating likelihood ratios and classification statistics. Logistic regression compared discrimination (areas under receiver operating characteristic curves), multivariable calibration and accuracy of the JFI and, separately, ADLs, in predicting 1-year outcomes. Hall-Wellner bands facilitated contrasts of JFI- and ADL-stratified 5-year community survival.

Results

Likelihood ratios rose evenly across JFI risk categories. Areas under the curves of functional dependency at ≥3 and ≥ 2 for JFI, age and sex models were 0.807 [95% c.i.: 0.795, 0.819] and 0.812 [0.801, 0.822], respectively. The area under the LTI curve for JFI and age (0.781 [0.747, 0.815]) discriminated less well than the ADL-based model (0.829 [0.799, 0.860]). Community survival separated by JFI strata was comparable to ADL strata.

Conclusions

The JEN Frailty Index with demographic covariates is a valid claims-based measure of concurrent activities-of-daily-living impairments and future long-term institutionalization risk in older populations lacking functional information.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3689-2) contains supplementary material, which is available to authorized users.

Ten Things Every Geriatrician Should Know About House Calls

Home-based primary care (HBPC) is experiencing a reemergence to meet the needs of homebound older adults. This brief review based on existing literature and expert opinion discusses 10 key facts about HBPC that every geriatrician should know: (1) the team-based nature of HBPC is key to its success; (2) preparations and after-hour access for house calls are required; (3) home safety for the clinician and patient must be considered; (4) being homebound is an independent mortality risk factor with a high symptom burden; (5) home care medicine presents unique benefits and challenges; (6) a systems-based approach to care is essential; (7) HBPC is a sustainable model within value-based care proven by the Department of Veterans Affairs and the Independence at Home Medicare Demonstration Project; (8) HBPC has an educational mission; (9) national organizations for HBPC include American Academy of Home Care Medicine and Home Centered Care Institute; and (10) practicing HBPC is a privilege. HBPC is a dynamic and unique practice model that will continue to grow in the future. J Am Geriatr Soc 67:139-144, 2019.

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

BACKGROUND

Medically 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.

METHODS

An 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.

RESULTS

Nearly 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).

CONCLUSIONS

Despite 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.

The Resurgence of Home-Based Primary Care Models in the United States

This article describes the forces behind the resurgence of home-based primary care (HBPC) in the United States and then details different HBPC models. Factors leading to the resurgence include an aging society, improved technology, an increased emphasis on home and community services, higher fee-for-service payments, and health care reform that rewards value over volume. The cost savings come principally from reduced institutional care in hospitals and skilled nursing facilities. HBPC targets the most complex and costliest patients in society. An interdisciplinary team best serves this high-need population. This remarkable care model provides immense provider satisfaction. HBPC models differ based on their mission, target population, geography, and revenue structure. Different missions include improved care, reduced costs, reduced readmissions, and teaching. Various payment structures include fee-for-service and value-based contracts such as Medicare Shared Savings Programs, Medicare capitation programs, or at-risk contracts. Future directions include home-based services such as hospital at home and the expansion of the home-based workforce. HBPC is an area that will continue to expand. In conclusion, HBPC has been shown to improve the quality of life of home-limited patients and their caregivers while reducing health care costs.

Teaching Home-Based Primary Care

Despite the growing homebound population and the development of innovative models of care that work to bring care to people in their homes, home visits are not a routine part of education for many healthcare providers. This manuscript describes the experience of Mount Sinai Visiting Doctors teaching home-based primary care to learners of various disciplines and reports the results of a survey performed to assess trainee experience. Mount Sinai Visiting Doctors is the largest academic home-based primary care program in the country and trainees of various disciplines have nearly 1,700 contact days annually of directly supervised clinical teaching. In order to improve trainee education and meet our practice needs, trainees: 1) independently conduct urgent visits, 2) carry longitudinal panels of homebound patients, and 3) perform subspecialist consultations. Mount Sinai Visiting Doctors has exposed thousands of trainees to home-based primary care in the past 20 years and trainees report positive reviews of their experiences. As the need to train future providers in home-based primary care grows, we will be challenged to provide trainees with adequate exposure to multidisciplinary teams and to teach about the importance of continuity of care.

Substance use disorders and medical comorbidities among high-need, high-risk patients with diabetes

BACKGROUND

The majority of the U.S. healthcare resources are utilized by a small population characterized as high-risk, high-need persons with complex care needs (e.g., adults with multiple chronic conditions). Substance use disorders (SUDs) and mental health disorders (MHDs) are a driver of poor health and additional healthcare costs, but they are understudied among high-need patients.

OBJECTIVE

We examine the prevalence and correlates of SUDs and MHDs among adults with high-risk diabetes, who are patients at the top 10% risk score for developing poor outcomes (hospital admission or death).

METHODS

A risk algorithm developed from Duke University Health System electronic health records (EHRs) data was used to identify patients with high-risk diabetes for targeting home-based primary care. The EHR data of the 263 patients with high-risk diabetes were analyzed to understand patterns of SUDs and MHDs to inform care-coordinating efforts.

RESULTS

Both SUDs (any SUD 48.3%, alcohol 12.5%, tobacco 38.8%, drug 23.2%) and MHDs (any MHD 74.9%, mood 53.2%, sleep 37.3%, anxiety 32.7%, schizophrenia/psychotics/delusional 14.8%, dementia/delirium/amnestic/cognitive 14.4%, adjustment 9.1%) were prevalent. Overall, 81.7% of the sample had SUD or MHD. Elevated odds of SUD were noted among men (tobacco, alcohol) and those who were never-married (alcohol, cannabis). African-American race (vs. other race/ethnicity) was associated with lower odds of anxiety disorders.

CONCLUSION

While data are limited to one large academic health system, they provide clinical evidence revealing that 82% of patients with high-risk diabetes had SUD and/or MHD recorded in their EHRs, highlighting a need for developing service models to optimize high-risk care.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

The effects of home-based primary care on Medicare costs at Spectrum Health/Priority Health (Grand Rapids, MI, USA) from 2012-present: a matched cohort study

Background

In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. However, there are relatively few studies of either the medical outcome effects or cost benefits of HBPC. In this paper, we examine medical cost and mortality outcomes for enrollees in the HBPC program offered by Spectrum Health/Priority Health (SH/PH), a not-for-profit integrated health care/health insurance system located in Grand Rapids, MI, USA.

Methods

We perform a concurrent matched cohort study. SH/PH HBPC enrollees during 2012–2014 are matched for prior costs, age, sex and comorbidities against controls selected from unenrolled insurance plan members. Twelve and twenty four-month medical costs are compared between HBPC participants and matched controls, overall and conditional on mortality status. Mortality rates of HBPC participants are studied on their own and in comparison to controls.

Results

At 12 and 24 months, in comparison to matched controls HBPC participants show higher ($2933) and lower ($8620) costs respectively. Relative costs and savings of HBPC participants are a function of short term increased costs upon entry into the program (enrollees who survive the first year cost $5866 more than controls); substantial savings at end-of-life (approximately $37,037 in savings relative to controls are realized); and the overall mortality of HBPC participants (mean residual lifespan is 37.75 months from the time of enrollment). We project the present value of lifetime medical cost savings due to enrollment in the HBPC program to be at least $14,336.

Conclusions

The SH/PC HBPC program reduces healthcare costs while enabling frail elders to remain at home. Reduction in costs is obtained at end-of-life and is offset with a smaller initial increase in costs upon enrollment.

Population Health and Tailored Medical Care in the Home: the Roles of Home-Based Primary Care and Home-Based Palliative Care

With the growth of value-based care, payers and health systems have begun to appreciate the need to provide enhanced services to homebound adults. Recent studies have shown that home-based medical services for this high-cost, high-need population reduce costs and improve outcomes. Home-based medical care services have two flavors that are related to historical context and specialty background-home-based primary care (HBPC) and home-based palliative care (HBPalC). Although the type of services provided by HBPC and HBPalC (together termed "home-based medical care") overlap, HBPC tends to encompass longitudinal and preventive care, while HBPalC often provides services for shorter durations focused more on distress management and goals of care clarification. Given workforce constraints and growing demand, both HBPC and HBPalC will benefit from working together within a population health framework-where HBPC provides care to all patients who have trouble accessing traditional office practices and where HBPalC offers adjunctive care to patients with high symptom burden and those who need assistance with goals clarification. Policy changes that support provision of medical care in the home, population health strategies that tailor home-based medical care to the specific needs of the patients and their caregivers, and educational initiatives to assure basic palliative care competence for all home-based medical providers will improve access and reduce illness burden to this important and underrecognized population.

Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies

Background

Home-based primary care (HBPC) is a multidisciplinary, ongoing care strategy that can provide cost-effective, in-home treatment to meet the needs of the approximately four million homebound, medically complex seniors in the U.S. Because there is no single model of HBPC that can be adopted across all types of health organizations and U.S. geographic regions, we conducted a six-site HBPC practice assessment to better understand different operation structures, common challenges, and approaches to delivering HBPC.

Methods

Six practices varying in size, care team composition and location agreed to participate. At each site we conducted unstructured interviews with key informants and directly observed practices and procedures in the field and back office.

Results

The aggregated case studies revealed important issues focused on team composition, patient characteristics, use of technology and urgent care delivery. Common challenges across the practices included provider retention and unmet community demand for home-based care services. Most practices, regardless of size, faced challenges around using electronic medical records (EMRs) and scheduling systems not designed for use in a mobile practice. Although many practices offered urgent care, practices varied in the methods used to provide care including the use of community paramedics and telehealth technology.

Conclusions

Learnings compiled from these observations can inform other HBPC practices as to potential best practices that can be implemented in an effort to improve efficiency and scalability of HBPC so that seniors with multiple chronic conditions can receive comprehensive primary care services in their homes.

First-Year Internal Medicine Residents' Reflections on Nonmedical Home Visits to High-Risk Patients

PROBLEM

Patients who are high utilizers of care often experience health-related challenges that are not readily visible in an office setting but paramount for residents to learn. A nonmedical home visit performed at the beginning of residency training may help residents better understand social underpinnings related to their patient's health and place subsequent care within the context of the patient's life.

INTERVENTION

First-year internal medicine residents completed a nonmedical home visit to an at-risk patient prior to seeing the patient in the office for his or her first medical visit.

CONTEXT

We performed a thematic analysis of internal medicine interns' (n = 16) written narratives on their experience of getting to know a complex patient in his or her home prior to seeing the patient for a medical visit. Narratives were written by the residents immediately following the visit and then again at the end of the intern year, to assess for lasting impact of the intervention. Residents were from an urban academic residency program in Baltimore, Maryland, USA.

OUTCOME

We identified four themes from the submitted narratives. Residents discussed the visit's impact on future practice, the effect of the community and support system on health, the impact on the depth of the relationship, and the visit as a source of professional fulfillment. Whereas the four themes were present at both time points, the narratives completed immediately following the visit focused more on the themes of impact of future practice and the effect of the community and support system on health. The influence of the home visit on the depth of the relationship was a more prevalent theme in the end-of-the-year narratives.

LESSONS LEARNED

Although there is evidence to support the utility of learners completing medical home visits, this exploratory study shows that a nonmedical home visit can be rewarding and formative for early resident physicians. Future studies could examine the patient's perspective on the experience and whether a nonmedical home visit is a valuable tool in other patient populations.

Evaluating a novel Integrated Community of Care (ICoC) for patients from an urbanised low-income community in Singapore using the participatory action research (PAR) methodology: a study protocol

INTRODUCTION

Poorer health outcomes and disproportionate healthcare use in socioeconomically disadvantaged patients is well established. However, there is sparse literature on effective integrated care interventions that specifically target these high-risk individuals. The Integrated Community of Care (ICoC) is a novel care model that integrates hospital-based transitional care with health and social care in the community for high-risk individuals living in socially deprived communities. This study aims to evaluate the effectiveness of the ICoC in reducing acute hospital use and investigate the implementation process and its effects on clinical outcomes using a mixed-methods participatory action research (PAR) approach.

METHODS AND ANALYSIS

This is a single-centre prospective, controlled, observational study performed in the SingHealth Regional Health System. A total of 250 eligible patients from an urbanised low-income community in Singapore will be enrolled during their index hospitalisation. Our PAR model combines two research components: quantitative and qualitative, at different phases of the intervention. Outcomes of acute hospital use and health-related quality of life are compared with controls, at 30 days and 1 year. The qualitative study aims at developing a more context-specific social ecological model of health behaviour. This model will identify how influences within one's social environment: individual, interpersonal, organisational, community and policy factors affect people's experiences and behaviours during care transitions from hospital to home. Knowledge on the operational aspects of ICoC will enrich our evidence-based strategies to understand the impact of the ICoC. The blending of qualitative and quantitative mixed methods recognises the dynamic implementation processes as well as the complex and evolving needs of community stakeholders in shaping outcomes.

ETHICS AND DISSEMINATION

Ethics approval was granted by the SingHealth Centralised Institutional Review Board (CIRB 2015/2277). The findings from this study will be disseminated by publications in peer-reviewed journals, scientific meetings and presentations to government policy-makers.

TRIAL REGISTRATION NUMBER

NCT02678273.

Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study

Background

Veterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions.

Methods

A qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs.

Results

There was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs.

Conclusions

Since program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings.

Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services

A path-breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administration's (VHA's) planned roll-out of a program for providing participant-directed home- and community-based services to veterans with cognitive and functional limitations. We describe the design of a large-scale, stepped-wedge, cluster-randomized trial of the Veteran-Directed Home- and Community-Based Services (VD-HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD-HCBS to veterans at risk of nursing home placement. Services will be provided to community-dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence-based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long-Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD-HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD-HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHA's randomized rollout of VD-HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReC's experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large-scale evaluations of delivery system innovations targeted to older adults.

A Claims-Based Examination of Health Care Costs Among Spouses of Patients With Alzheimer's Disease

Background

Spouses of Alzheimer's disease patients (AD spouses) may experience substantial health effects associated with their partner's chronic cognitive and behavioral dysfunction. Studies examining associations between the medical experiences of AD spouses in the period before and after their partner's AD diagnosis are limited, particularly those which measure health care resource use and cost.

Methods

AD patients were identified through multiple Medicare claims containing an AD diagnostic code. Their spouses were identified through special coding in the Medicare eligibility records. The AD spouses were matched demographically to the spouses of Medicare beneficiaries without a history of AD. Longitudinal and annual cross-sectional Medicare cost comparisons utilized log-transformed linear regression. The longitudinal period of observation began 12 months before the AD patient's initial claim listing AD and continued for up to 38 months afterwards.

Results

The study identified 16,322 AD spouses. Total per person costs were 24% higher in AD spouses than in the controls ($694/month vs $561/month). AD spouses' excess costs began 3 months before their partners' AD diagnoses and continued for ≥30 months. Being an AD spouse predicted 29% higher Medicare costs after adjustment for chronic health status (P < .001). Increasing AD patient care complexity had a substantial impact on AD spouse Medicare costs (P < .001).

Conclusions

This study documents a link between the health status of AD spouses and AD patients. Additional research is required to elicit the mechanism behind the association between AD spouse and AD patient diagnosis.

Frailty in community-dwelling older adults: association with adverse outcomes

BACKGROUND

The study of frailty is important to identify the additional needs of medical long-term care and prevent adverse outcomes in community dwelling older adults. This study aimed to determine the prevalence of frailty and its association with adverse outcomes in community dwelling older adults.

METHODS

A cross-sectional study was carried out from April to September 2014. The population sample was 1,252 older adults (≥60 years) who were beneficiaries of the Mexican Institute of Social Security (IMSS) in Mexico City. Data were derived from the database of the "Cohort of Obesity, Sarcopenia and Frailty of Older Mexican Adults" (COSFOMA). Operationalization of the phenotype of frailty was performed using the criteria of Fried et al (weight loss, self-report of exhaustion, low physical activity, slow gait, and weakness). Adverse outcomes studied were limitation in basic activities of daily living (ADLs), falls and admission to emergency services in the previous year, and low quality of life (WHOQOL-OLD).

RESULTS

Frailty was identified in 20.6% (n=258), pre-frailty in 57.6% (n=721), and not frail in 21.8% (n=273). The association between frailty and limitations in ADL was odds ratio (OR) =2.3 (95% confidence interval [CI] 1.7-3.2) and adjusted OR =1.7 (95% CI 1.2-2.4); falls OR =1.6 (95% CI 1.2-2.1) and adjusted OR =1.4 (95% CI 1.0-1.9); admission to emergency services OR =1.9 (95% CI 1.1-3.1) and adjusted OR =1.9 (95% CI 1.1-3.4); low quality of life OR =3.4 (95% CI 2.6-4.6) and adjusted OR =2.1 (95% CI 1.5-2.9).

CONCLUSION

Approximately 2 out of 10 older adults demonstrate frailty. This is associated with limitations in ADL, falls, and admission to emergency rooms during the previous year as well as low quality of life.

Integrating Social Services and Home-Based Primary Care for High-Risk Patients

There is a consensus that our current hospital-intensive approach to care is deeply flawed. This review article describes the research evidence for developing a better system of care for high-cost, high-risk patients. It reviews the evidence that home-centered care and integration of health care with social services are the cornerstones of a more humane and efficient system. The article describes the strengths and weaknesses of research evaluating the effects of social services in addressing social determinants of health, and how social support is critical to successful acute care transition programs. It reviews the history of incorporating social services into care management, and the prospects that recent payment reforms and regulatory initiatives can succeed in stimulating the financial integration of social services into new care coordination initiatives. The article reviews the literature on home-based primary care for the chronically ill and disabled, and suggests that it is the emergence of this care modality that holds the greatest promise for delivery system reform. In the hope of stimulating further discussion and debate, the authors summarize existing viewpoints on how a home-centered system, which integrates social and medical services, might emerge in the next few years.

How’s Your Health at Home: Frail Homebound Patients Reported Health Experience and Outcomes

Pour notre sondage, nous avons utilisé une méthodologie mixte basée sur le Web (How’s Your Health – Frail) pour examiner la santé des adultes fragiles (78% âgés de 80 ans et plus) inscrits à un programme de soins primaires à domicile à Vancouver, au Canada. Soixante pour cent des répondants admissibles ont participé, représentant plus d’un quart (92/350, 26,2%) de tous les individus qui reçoivent le service. Malgré des niveaux élevés de co-morbidité et de dépendance fonctionnelle, 50% ont jugé leur santé aussi bonne, très bonne ou excellente. Les ratios de cotes ajustés pour l’auto-évaluation de sa santé positive étaient de 7,50, 95 pour cent d’intervalle de confiance (IC) [1,09, 51,81] et 4,85, 95% CI [1,02, 22,95] pour l’absence de symptômes gênants et le pouvoir de parler à la famille ou amis, respectivement. Des réponses narratives aux questions sur la fin de vie et la vie avec une maladie sont également décrites. Les résultats suggèrent que l’accent mis sur la gestion des symptômes, et le soutien des contacts sociaux, peut améliorer la santé des personnes âgées fragiles.