A Home Care Practice That Works (For Syllabus)

A Home Care Practice That Works Dr. Ted Rosenberg Dr. Jay Slater

Objectives
Outline 2 models of home care practices
Funding
Staffing
Describe patient populations
Review “goals”
Discuss services and interventions (“A day in the life”)

Objectives
Illustrative cases
Discuss relevance of clinical practice guidelines
Measuring outcomes

Home ViVE Program
“ Home Visits to Vancouver’s Elders”

The Office

The Office Assistant

The Office Manager

The Mandate
Providing comprehensive care to frail elderly patients in their homes
Keeping our patients out of hospital as much as possible
Keeping our patients in their homes and out of care facilities as much as possible

The Team
Hester Chan – Part-time MOA
Gisela Jaschke – RN, Case Manager
Drs. Rod Ma, Conrad Rusnak and Jay Slater – all doing half-time home care practices

The Extended Team
Home Care Nurses
Home Care Physio and OT
Case Managers
Geriatric Triage Nurses (ER)

The Virtual Team
Mobile Lab
Mobile Podiatry, Optometry
Palliative Care, Mental Health teams
Geriatric Day/In-Patient Programs
Etcetera…

Model #1
Publicly-funded
Fee for Service
Supported with “Community” funds (office space, support staff, RN)

The Practice
124 patients at intake
32 lost to death or long-term care
20 deaths (all but 3 died out of hospital)
5 found other care
30 new patients to practice
117 patients at present

The Practice
Demographic
Really Old (85 years)
Really Complex
“ Patients who are unable on a consistent basis to get out for medical care and/or whose current Family Physician can’t consistently provide home visits”

Referrals to Program
Case Managers, Home Care Nurse
ER Personnel
Hospitalists, Case Managers
Geriatric Programs
Mental Health, Palliative Care teams

The Practice

The Practice
The group with “No Chronic Disease” include frail, house-bound patients with:
Advanced Parkinson’s
Advanced MS
CMT
Advanced Cancer
Advanced AIDS
Severe Arthritis

Challenges
Defining Goals
Assessing Frailty
MSC has put “patient convenience” into the exclusion for billing a house call
Appropriate use of Clinical Guidelines
Technology (mobile EMR)
“ Right-sizing” the practice

Evidence-based clinical practice guidelines (CPGs) are increasingly popular as tools for improving quality of care, but Dr Cynthia M Boyd (Center on Aging and Health, Johns Hopkins Medical Institutions, Baltimore, MD) argues that they provide poor guidance for the care of the older patient with multiple comorbid diseases. This has major implications for clinicians treating older patients, since adherence to such guidelines is often used as the basis for pay-for-performance reimbursement decisions. Adhering to CPGs for one chronic condition may cause other problems or exaccerbate other existing diseases. August 10, 2005 issue of the Journal of the American Medical Association .

Case #1 –Mrs. N. E.
97 y widow
Other than blindness no significant medical history. Visits “prn”
Stoic – “Few weeks of weakness and swelling in the feet”
Rapid A. Fib, Crackles and edema to knees = CHF

Case #1
Diuresed with Lasix
Rate reduced with Metoprolol then controlled with Digoxin
Warfarin started for CVA prophylaxis
RN / Case Mgr able to monitor weight and clinical status, and offer home support

Case #1
Symptoms improved over weeks
Patient then revealed a skin wound on her L shin that she’d been treating herself
RN’s visit for dressings, antibiotics for associated cellulitis - resolved
Regular follow up visits to monitor symptoms, clinical exam and weight

Outcomes
38% of patients visited ER at least once in the 27 months prior to ViVE
12% of patients visited ER at least once after ViVE
Of those previously visiting ER, 31% have had no further ER visits since ViVE

The secret weapon

The Co-Secret Weapon Over 50

Victoria Practice Profile
N= 328
Live in homes = 260 (80%)
Nursing Home = 68 (20%)
Functional Status and Risk- Average:
Age 87.9
Tug 21. (n<10sec) - couldn’t cross street /# risk
Berg Balance Scale- 38.1- risk of fall and # - but in range for rehab and conditioning
30-40% die at home in own beds

Victoria Practice Profile
Problems n= 328
Dementia- 100
Chronic Pain (on narcotic)- 72
CHF -57
O2- 13
Parkinson’s on treatment-25
Anticoagulated – 53
Complex medical conditions: Rheum, Neurodegen eg ALS Parkinson +, ,pulm HTN/Fibrosis, Heme, onc, ID

Victoria Team
Team
Direct Members
1 MD
1.6 RN/gerontological nurses –directors of care (Vikki Hay, Anne Adams)
0.6 Physiotherapy/kinesiology (Carey Adams)
MOA (Liza Zacharias)
Patients, caregivers and families
Indirect Members
SLP- community – swallowing
Lab
Pharmacists
Case Managers
Community HC teams, Hospice etc

Team
Nursing services
Functional Assessments, MMSE, GDS etc
CDM chronic disease management
Monitor impact of drug changes- eg start ACHEI, sinemet etc
Bowel and Bladder Care/education – eg catheters and enema/disimpaction
Time consuming Procedures-Syringing ears, Ulcer Dressing Unas Boots
Injections (eg monthly depomedrol, iron) Immunization
Acute Care

Physiotherapy Pilot 3 phases
Phase 1 – Jan- March . 2009
Assess treatment needs and resources for people
Compile standardized profile of individuals and group (eg berg balance, TUG etc)
Test assessment forms and work flow
Phase 2 April –June
Consolidate procedures, evaluate individ service
plan roll out for Group exercise program.
Phase 3 – Nursing Homes Survey - July - Aug
Assess needs of nursing home patients

Communication Virtual Team
Electronic Record- Tablet PC
Meet in room for business- every 1-2 months
Meet everyday- multiple times
Cell phone
Text Message
Mrs. J. (Exac COPD). Coughing green sputum wheezing, b. basal crackles and edema temp 38.5 O2 saturation 93%,
Allergy : emycin-vomit, penicillin
Pharm@ 250-386-7111
I call in: prednisone,Moxi, Lasix
They see the next day
Email- Team Report- progress notes from day and comment

Goals of Care
In addition to reducing acute care and delaying LTC:
Enhance QOL
Control Disabling symptoms
Maximize function
Provide frail seniors with choice and control

Goals Families and Caregivers
Reduce Caregiver Burden
Reduce work loss and time taking parent to doctor’s office
Provide information about health status, medications and treatment plan- they don’t feel they are working with one hand tied behind back and blind folded
Prognosticate
Can stay home
Time look at alternative housing
Type of support

Can we reduce costs?
Practice profile-outlier
investigations
Costs vs Cost-effectiveness

99 year old male
Completely independent- history of multiple skin cancers
One “sprouted”- “lets wait”
2 months
Severe pain- allergy to acetoaminophen
Delirious with narcotics
Sleepless
Falling
24 hour care-private/public 4 hours per day
Referred for – daily radiotherapy for 14 days
Exhausting
Pain is gone and tumour is regressing
Cost to system v cost to family and patient

Costs of Care MSP – 2007 Profile
Me ($)/pte GP Median ($) Age/gender
Case Mix Adjusted $
Medical- 653 102 1.22 ( 1.4)
Consult -392 72 0.65 (0.68)
Total MD- 0.88 (0.93)
Lab - 203 26 1.01 (.99)
Xray - 48 9
Total - $ 1294 $ 208 Morbidity Ratio 1.37-1.57

Costs of Care -summary
Patients are higher morbidity even after adjusting age/gender Summary-
After adjustment for age, gender and case-mix
Physician Costs are less
Consults are less
Lab is the same
Does not include Cost Savings
Emergency visits Saved (>$1000/visit)
Hospital Days Saved
Nursing home days
Cost/Quality Adjusted Life year

Differences in Funding
Public
Bill MSP for direct medical care – pays salaries, equipment (eg Tablet PC’s support) and Overhead
Private (Annual Practice fee or pay as you go)- services not covered by MSP
Team
Indirect Contact: phone, email, family meetings Multitude of forms etc

Complex Team Primary Care Case Presentation
End of Nov.2008 Call from Experienced HCN
“ Help”
91 year old lady living with husband in old house in Oak Bay- failing in community
Home situation falling apart
Palliative Care?

Initial Assessment
Severe Depression- GDS 5/5; refusing MMSE (subsequent 22/27)- “I want euthanasia”
Cachectic
Severe Parkinsons
Drooling
Wheelchair – 1 person assist transfers
Shuffle few steps
Falling
Severe tremor right hand

Initial Assessment
Up hourly
Urine
Restless legs and dystonia, aching in thighs
Severe Constipation – last BM 6 days ago-”told by Dr. to avoid laxitives”
Deaf –impacted wax in ears
Visual Impairment AMD
Decubitus on Coccyx- horse shoe painful callus

Initial Assessment
Neglect
Long Beard and Moustache
Hair Stringy
Blue/green mould in ear canal
Cluttered House
Pills all over the place
Husband trouble staying awake and insisting on managing pills
Paid CG at lunch cowering in kitchen
You can’t help us –leave us alone

Where Do You Begin?
Can you do this in an office?

Careplan/interventions
MD
Blister Pack meds-
Husband took them out and put into dosette
Agreed to let paid caregiver review
Imipramine –stopped the drooling and reduced nocturia to 1x/night
Parkinson’s
Moved Requip to HS – end of RLS
Added rapid acting sinemet in a.m. to jump start in a.m
and spread out CR to 4 x day. 3 weeks later added comtan over 2 weeks
AM Care – went from 3 hours to 1 hour and up at 9:00
Tremor –better could use eating utensils
Independent to stand by with transfers and walking in house

Interventions
Depression
Partial Improvement- added effexor
GDS 0- “changed my mind about euthanasia”
NSg
Syringed ears- could communicate
Started Lactulose
BP – 180 – added felodipine
Chocolate ensure and diet
Baza cream for ulcer and education
Called Daughter- re: shave, hair and bath assist, increase HSW
PT- Roho cushion, Equip change, resistance exercises

Summary
8 weeks- “building trust and going with their priorities”
4 MD visits
4 nursing Visits
2 PT visits
Phone calls – 8 the first week and none the last 3 weeks
Outcome
Depression resolved
No longer drooling
Waking up 1-2x at night to void
No pain from dystonia/rls
Independent with mobility and walker
ADL time in a.m reduced from 4 hour – 1 hour
Dtr and caregiver Thrilled- Pte happy – husband not so sure

Conclusion
For Frail Elderly, Home Based care
Better assessment of individual, environment and supports and complex needs
Improved access to care for people who could not get out to a doctor’s office easily
Better Outcomes
Frail Elderly – QOL, function, choices,
Caregivers- reduce emotional and economic strain (eg time off work for appointments)
Health Care System – keep out of ER and delay Nursing Home Placement and Direct costs after adjustment for age gender and case mix

A Home Care Practice That Works (For Syllabus)

by BCAGCP on Mar 20, 2009

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A Home Care Practice That Works (For Syllabus) — Presentation Transcript