home based primary care: an interdisciplinary model of care in the department of veterans affairs
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Home Based Primary Care: An Interdisciplinary Model of Care in the Department of Veterans Affairs
Mandy McCorkindale, PsyDClinical Psychologist, Home Based Primary Care
Julie Ruple, PharmD, CGPClinical Pharmacist, Home Based Primary Care
Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session #E5aOctober 18, 2014
Faculty Disclosure
• We have not had any relevant financial relationships during the past 12 months.
Learning Objectives
At 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.
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 Affairshttp://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp#
Goals for HBPC Promoting health and independence
Reducing the 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
Supporting the caregiver in the care of the veteran
(Beales & Edes, 2009)
Goals for HBPC Meeting the changing needs of the veteran and family
Enhancing the veteran’s quality of life through symptom management and other comfort measures
Allowing the veteran the option of dying at home rather than in an institution
Helping the veteran & family cope with chronic disease
Providing an academic and clinical setting for training
(Beales & Edes, 2009)
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)
Rationale for Cost
Cost Reduction Seen Through: Results:
fewer inpatient hospitalizations 56% reduction in hospital Bed Days of Care (BDOC)
decrease in readmission rates 78% reduction in inpatient days of care
decrease in nursing home placements 84% reduction in nursing home BDOC
overall reduction in combination of VA and Medicare utilization and costs
HBPC associated with a 25% reduction in hospital admissions, 36% reduction in hospital days, and 13% reduction in total VA plus Medicare costs after accounting for the cost of HBPC
(Edes, 2010) (North, Kehm, Bent, & Hartman, 2008)
Patient & Caregiver
MD
APRN
Psychologist
OT
Social Worker
Dietitian
Pharmacist
RN
Admin & Support
StaffChaplain
Other Home Care
Services
Medical Foster Home
The TEAM!!
PHYSICIAN
• Supervise overall patient care
• May admit patients or make home visits• Integral part of Treatment Plan development
and monitoring
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
RN
• Assesses patient’s needs in the home
• Fill mediplanners when appropriate
• Telephone triage on weekends
Social Worker
• Maximize benefits (VA and nonVA)
• Assesses veteran’s relationships
• Education for advance directives and DNR• Ongoing assessment of appropriateness for
HBPC program
Dietitian
• Ongoing assessment of nutritional status
• Recommends nutritional adjustments in management of chronic conditions
• Dietary guidance for current condition or prevention of exacerbations
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
Pharmacist
Pharmacist
• Function under Scope of Practice
• Medication education (interprofessional,
patients, and students)
• Quality Assurance
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
PsychologistWhy 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)
PsychologistTop 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)
The Effective Interprofessional Team
• Relationship development over time
• Understanding / respecting all roles
• Complementary skills
• Committed to a common goal
• Ongoing communication plan
(Sargeant, Loney, & Murphy, 2008)
Challenges
• Geographically challenging
• Changing the perception of services provided
• Establishing boundaries
• Patient goals: aggressive vs comfort
• Caregiver frailty
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)
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!”
BibliographyBeales, 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.
BibliographyHughes, 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
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!