HOME-BASED PRIMARY CARE (HBPC)

1. HOME-BASED PRIMARY CARE (HBPC) A VA INNOVATION COMING SOON TO YOUR COMMUNITY THOMAS EDES, MD, MS JAMES F. BURRIS, MD, CPE APRIL 2013

2. WHAT IS HBPC? • Comprehensive longitudinal primary care • Delivered in the Veteran’s home • By an interdisciplinary team that includes a physician medical director, a program director (administrative support), and staff from nursing, social work, rehabilitation, dietetics, pharmacy, mental health, and pastoral care.

3. TARGET POPULATION Veterans with complex, chronic and disabling disease Routine outpatient care has proven ineffective (“too sick to come to clinic”) High utilization of emergency and inpatient services Not age-limited (though most are elderly)

4. OBJECTIVES OF HBPC • Maximize the independence of the patient • Reduce unnecessary hospitalizations, nursing home admission, emergency visits • Assist with transitions in level of care • Support and train the caregiver • Provide ongoing care, often through the end of life.

5. DEMOGRAPHICS OF HBPC PATIENTS • Mean age 76.5 years • 96% male • More than 8 chronic medical conditions • 47% dependent in 2 or more ADL • 47% married, 29% live alone • 32% of caregivers have limited ADL • Mean duration of HBPC enrollment 315 days

6. DISEASE PREVALENCE IN HBPC ENROLLEES MEDICAL CONDITION % WITH CONDITION • Heart disease 72% • Diabetes 48% • Depression 44% • Heart failure 35% • Dementia 33% • Substance abuse 29% • Cancer 29% • Anxiety/Personality disorder 24% • PTSD 21% • Schizophrenia 20%

7. HBPC OUTCOMES • 83.7% of enrollees rate their care as Very Good or Excellent • 62% reduction in hospital bed days of care • 88% reduction in nursing home BDOC • 24% net reduction in total costs of care (including cost of HBPC) • 13% net reduction in total combined VA and Medicare costs for dually eligible Veterans

8. DIFFERENCES BETWEEN HBPC AND MEDICARE HOME CARE • Remediable conditions • Specific problem-focused • Requires skilled care • Must be homebound • Requires improvement • One or multidisciplinary • Episodic post-acute care • No definitive impact • Anywhere, anytime Targets complex chronic disease Comprehensive primary care Skilled care not required Strict homebound not required Accepts declining status Interdisciplinary team care Continuous longitudinal care Reduces BDOC and costs of care Limited geography & intensity

9. THE INDEPENDENCE AT HOME DEMONSTRATION PROGRAM • DEMONSTRATION PROJECT USING HOME-BASED PRIMARY CARE FOR MEDICARE BENEFICIARIES • CONDUCTED BY THE CENTER FOR MEDICARE AND MEDICAID INNOVATION WITHIN CMS • TARGETS THE HIGHEST COST MEDICARE BENEFICIARIES WITH MULTIPLE CHRONIC ILLNESS • TO ENROLL AT LEAST 5,500 PATIENTS FOR A THREE YEAR PERIOD

10. THE INDEPENDENCE AT HOME DEMONSTRATION PROGRAM • 16 MEDICAL PRACTICES SELECTED TO PARTICIPATE IN APRIL 2012 AND ADDITIONAL 3 CONSORTIA OF PRACTICES IN AUGUST 2012 • CMS WILL TRACK PATIENTS’ CARE EXPERIENCE WITH SEVERAL QUALITY MEASURES • PRACTICES THAT ACHIEVE SAVINGS IN EXCESS OF 5% OF TOTAL COSTS WILL SHARE IN THE SAVINGS • IF DEMONSTRATION IS SUCCESSFUL, CMS PLANS TO EXPAND THE PROGRAM NATIONALLY