Home-Based Care

(Jessica L. Colburn, MD Jennifer L. Hayashi, MD Bruce Leff, MD)

HOME-CARE MODELS

Specific home-care models have proven effective at providing high-quality care to vulnerable older adults. These models include preventive home care programs and medical house calls that integrate medical and social supportive services focusing on the care of chronically disabled persons, home geriatric assessment, posthospital case management/ transitional care models, home rehabilitation, and hospital at home.

PREVENTIVE HOME CARE/GERIATRIC ASSESSMENT

Many models of preventive home care for older adults at risk of functional decline have been described and evaluated. Models differ in their target populations, intensity and degree of geriatric assessment, and follow-up. Results of these studies are varied, but overall, programs that target high-risk patients and provide multidimensional assessment and multiple follow-up visits have demonstrated a reduction in nursing home admission, improvement in functional status, and reduction in mortality. The high initial cost currently makes this model rare in practice.

MEDICAL HOUSE CALLS

Medical house calls are visits to provide ongoing longitudinal medical care within the patient’s home environment. House call visits may be done by a physician alone, or patients may receive primary health care from a team, such as in the Home-Based Primary Care Program through Veteran’s Affairs facilities. In the house call team model, patients are cared for by a multidisciplinary team of physicians and other health care professionals, including, but not limited to nurses, home health aides, social workers, and physical and occupational therapists. Some programs

POSTHOSPITALIZATION CASE MANA & TRANSITIONAL CARE MODELS

Specific home-based case management strategi that are focused on conditions associated with complex management issues and high rates of early b mission (eg, congestive heart failure), are associated with a significant reduction in the number of acute hospital missions. HOME REHABILITATION

Home rehabilitation specifically after a stroke or am joint replacement) has proved to be feasible, acceptable to patients and caregivers, and as effective as hospital-based rehabilitation.

HOSPITAL AT HOME

Hospital at home models that provide hospital-level services in the home setting as a substitute for needed hospital admission have been developed and have demonstrated comparable clinical outcomes, reduced length of stay, decreased readmission rates, increased patient and caregiver satisfaction, and reductions in important geriatric complications such as delirium.

POSTACUTE HOSPITALIZATION & HOME REHABILITATION CARE

In posthospitalization care and home rehabilitation care, the focus is on restoring function and completing the management of medical problems. The interdisciplinary care team provides much of the care in this setting, with a physician providing medical oversight and supervision.

HOME CARE & ASSESSMENTS

In acute home care, the physician is actively involved in the management of acute illness. Physician home visits, home health agency involvement, and close coordination of the interdisciplinary care team are crucial to assess and manage the patient. In addition, assessment home visits, which may be performed on a one-time basis, allow a physician to evaluate the impact of the home environment, caregiver, or functional disability on the patient’s health, including nonadherence, difficult diagnoses, and excessive use of health services.

HOUSE CALLS & HOME-BASED PRIMARY CARE

In addition to the usual components of a patient encounter (ie, the history and physical examination and counseling), the house call permits and encourages functional, social, caregiver, and environmental assessments. Inspecting the home environment with patient/family permission (eg, clutter and obstacles, adaptive equipment, lighting, bathroom setup, kitchen setup, refrigerator contents, medication setup) can help the physician understand functional and medical issues. Also, observations of patient-caregiver interactions in the home are often remarkably different from those observed in the office setting and can provide valuable insight into management issues. Physicians may choose to do a single house call to assess particular aspects of a patient’s home environment or care needs, or a physician may provide primary care in the home setting. In some cases, physicians work with an interdisciplinary care team, including nurse practitioners, nurses, social workers, and home health aides, in a house call practice providing home-based primary care.

WHERE DO WE GO FROM HERE?

Focus on Person and Function Versus Patient and Disease:

Over the past 2 decades, significant dollars have been spent tackling the assumption that chronic illness alone drives health care use. Even though some tangible improvements and valid have been achieved, there is little evidence that “fixing the disease will directly result in better care and health outcomes at a lower cost. The reason is that targeting efforts have not been refined enough and have missed a key part of the equation.

how chronic disease (and often multiple diseases) impacts a person’s daily living, which requires a more robust discussion of functional status.

Our current health care system is built for patients” those people who are vessels for illness ideally on the road to wellness under the care of the medical system. This approach works well for a relatively healthy person facing an acute illness where a cure is almost always achievable. This model is fundamentally flawed however for individuals with serious chronic health conditions, as many will never be fully “well” the way a healthy 20-year-old recovers from pneumonia. As a result, people with chronic conditions risk getting stamped as “patients” for life. They get “patient-centered care” for their list of chronic illnesses as opposed to “person-centered care focused on their desires to retain choice and independence in their lives inclusive of health conditions and functional status. Addressing both the patient and the underlying person’s illness and its functional impact is the key to more effective targeting. About 110 million people in the United States live with chronic illness and nearly 32 million have serious functional limitations or key interest is the overlap in these 2 populations, accounting for 27 million people. More than 30% of older Medicare beneficiaries in the top spending quintile have both chronic conditions and functional limitations. On average, Medicare spends almost 3 times more per capita on seniors who live with chronic health conditions and functional impairment compared to seniors with chronic conditions alone. They were nearly twice as likely to have a hospital stay than those with chronic conditions alone. While roughly half of the seniors with chronic conditions and functional limitations qualify for Medicaid (dually eligible), more importantly, the other half do not. When an older adult with chronic conditions and functional limitations has a daily living crisis, even if not primarily medical in nature, the medical system and particularly hospitals are often the backstop. These data clarify that a chronic disease, “patient-only” perspective to care delivery is simply too broad an assumption for good targeting.

Focus on Quality

Given that older adults have care needs and preferences that are much different from those of a younger population, assessing the performance of providers and organizations should account for the comprehensive set of services delivered to this population.

In addition to existing quality metrics that are tested and validated, additional measures are needed to evaluate truly person-centered functional outcome measures that are site-neutral, focused on the coordination of services, and based on individual needs and preferences for care. For example, an older adult with severe diabetes complicated by visual problems and neuropathy may identify the ability to walk safely within the home” as a core preference-based outcome measure. This individual’s desired outcome, with these complex health and functional challenges, also has substantial medical and cost implications. The number of providers, sites of care, and services delivered to achieve this outcome may be many. However, the singular fact remains that functional improvement is what the older adult is seeking. The provision of these services and achievement of this outcome could forestall or mitigate negative and costly incidents, such as a fall resulting in a hip fracture and nursing home placement. None of the existing patient satisfaction or quality of care metrics adequately identifies or measures this functional-based, yet medically driven indicator