A New Age Marcus Welby. We all wanted to be Marcus Welby growing up. Bring care to where our patients live allows us to better understand them as individuals, their environmental and social challenges, and the diaphanous cloak of caregivers that surround them. Our populations are rapidly aging and becoming increasingly frail, afflicted with multiple chronic diseases. This population bounces in and out of your practice, in and out of hospital care, and may or may not end up in long term care.
Yet, our training in medical school and residency has focused on developing the skills to manage the intermittent patient in the office or hospital setting, and less or not at all on managing the health needs of our patients in their homes. Health systems have inhibited the reach of home based primary care through limitations of funding, and selective design of non-mobile technologies that restrict care to health settings able to support these technologies. All of that is changing.
Models of Home based Care. Care in the home is not a new concept. It is arguably the oldest form of care, and defined the role of physicians and health systems long before there were modern hospitals. The Veterans Administration (VA) has had a home based primary care (HBPC) program since 1970s. The CMS Independence at Home innovation program funded demonstration projects across the country in home based care. One of the most successful of these demonstration projects is the Sutter Health Advanced Illness Management (AIM) program which was started in the mid-2000s in Northern California.
What is Home Based Primary Care. Elements of home based primary care include:
- A team approach with physicians, advance practice nurses, social work, and others collaborating to provide an array of services in the home. The composition of the team flexes based on the changing needs of the patient.
- Focus is on care coordination. Most teams are led by a case manager who coordinates the team. Frequent communication through individual discussion or case conferences keep the care plan updated based on the patient needs
- HBPC seeks to be fully patient centric, designed to more than treat diseases. Beyond treatment or in the context of treatment, HBPC teams attempt to understand what the patient’s goals for care and for life
Does home based palliative care work? Evaluation of the VA HBPC program found a 24% reduction in cost (over $9000 savings per patient) despite four times more care being provided. The HBPC cohort showed a 59% reduction in hospital stays, and 89% reduction in SNF admissions, and a 21% reduction in hospital readmissions.
What you can do. Five things you can do today to develop your connection and reach in home based primary care include:
- Identify and engage with home health agencies in your community. What are their strengths and weaknesses? Do they employ physicians in oversight? Are they electronic? How do they interact and communicate with you?
- Set clear expectations for care and communication. What do you want them to do? How do you want them to communicate?
- Mutually set care goals with the home care team. Build into your practice time and method for communicating with the home care team, and updating care plans.
- Develop protocols, especially for urgent or changing situations. Be clear on the aspects of the care plan.
- Expand your network. Get to know who the local DME and physical therapy providers are, who are the area agencies on aging, what are the social service agencies in your communities.
Role of mobile technologies for HBPC. With the rise of a wide variety of mobile health technologies including communication (eg. videoconferencing, text messaging) and home monitoring are now allowing a shift away from clinic-based health care to a “24/7 inbound multichannel access to health care teams as well as proactive outbound support between visits”. This allows not only more effective home based primary care but also “hospital at home” models.