Factors Associated with Reduction in Inpatient Days by VA Home Based Primary Care 4.28.08

Factors Associated with Reduction in Inpatient Days by VA Home Based Primary Care (HBPC) Bruce Kinosian(1,2); Heather Tompkins(3); and Thomas Edes (3) for the HBPC Quality Improvement Work Group* (1) CHERP, Philadelphia VA Medical Center, Philadelphia, PA, (2) Division of General Internal Medicine, University of Pennsylvania, PA (3) Geriatrics & Extended Care, US Dept of Veterans Affairs(VA), Washington DC. *The HBPC QI work group members include: Jan Clarke; Wendy Hamlin; Karen Dutton; Larry Dixon; Heather Tompkins, and Bruce Kinosian Conclusions and Policy Implications Program Differences between Consistently Best and Worst Performing Programs Variation in Program Performance by Outcome Measure (Mean+/-SEM) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Background Determine factors that distinguish high from low performing HBPC programs in reducing inpatient days Objective Purpose : Improve outcomes in VA HBPC by identifying factors associated with reduction in inpatient days. HBPC provides comprehensive longitudinal primary care by an interdisciplinary team(IDT) in homes of veterans with chronic disabling disease who are too frail for clinic. Since 2005 VA assessed the impact of HBPC on inpatient days as a quality measure. Reduction of inpatient days for each HBPC program is reported quarterly, comparing inpatient days 6 months prior to HBPC vs during HBPC. The 2006 national mean indicated a 72% reduction in inpatient days; the range of -23% to 92% suggested that factors associated with high performance may guide improvement. Methods : HBPC national office sent a form to all HBPC Program Directors; 75 (77%) responded on 1) % with HBPC as primary provider, 2) primary provider as physician, nurse practitioner(NP) or collaboration, 3) extent of physician home visits, 4) nursing home or emergency department at program’s facility, 5) satellite HBPC, and 6) after hours care. The 75 programs were divided into tertiles by % inpatient reduction. Odds of a factor associated with greater reduction are relative to the worst-performing tertile. Results : For acute inpatient days the top tertile had a 68% reduction vs 7.3% in the lower tertile. The 10 lowest programs had increases in acute hospital days(3 to 340%); the top 10 had 78% reduction(67 to 100%). Factors associated with best performance were: MD/NP collaborate for primary care(OR 1.6); NP makes visits(OR 1.4); and HBPC is primary care for >50% of patients(OR 1.3). MD visits were more frequent in the top tertile(1.67 visits/pt vs 1.16 visits/pt); all visits/mo and patients/FTE were equivalent. Top tertile programs were more mature(avg 17.6 vs. 13.9yrs), and patients in program longer(avg LOS 331d vs 270d) Conclusions : Collaborative primary care of MD/NP on the IDT is associated with greater reduction in acute inpatient days in HBPC. Greater reductions are obtained by targeting patients with high inpatient days before HBPC. Weak structural factor associations suggest IDT function and all-inclusive primary care are important factors in reducing inpatient days. Abstract ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Methods ,[object Object],[object Object],[object Object],[object Object],Results ,[object Object],[object Object], Program Age Average Daily Census FTE/ ADC ALOS In HBPC MD visits/pt Total Visits/pt NP visit/pt HBPC as Prim Care> 50% MD/ NP Top 10 20 +/- 10.6 113.6 +/- 31 9.4 +/- 3.3 354 +/- 28 2.5 +/- 2.3 10.4 +/-2.8 1.8 +/- 2.2 1 1 Bottom 6 13.6 +/- 12.7 111 +/- 80 10.4 +/- 7.2 280 +/- 154 1.2 +/- 1 8.85 +/- 2.5 0.56 +/- 0.88 0.5 0.33 RR 1.26 2.1 1.1 3.2 2.0 3.0 All Acute/ Psych/LTC ) All Acute/ Psych/LTC All Acute/ Psych/LTC All Acute/ Psych/LTC Acute Acute Acute Acute Ranking Measure (All) Inpt Days/1000 Before HBPC Inpt days/1000 During HBPC Admits /100 Pt-M Reduction Inpt Days% Inpt Days/1000 Before HBPC Inpt days/1000 During HBPC Admits /100 PtM Reduction Inpt Days% Top tertile % Inpt Days Reduction 34675 +/- 6165 4854 +/- 481 6.3 +/- 2.9 84% 7701+/-1197 2956+/-394 4.8+/- 2.9 47% Admits/100 Pt-Months 16250 +/- 1810 3577+/-270 4.4 +/- 1.5 71% 3978+/-512 1679+/-175 3.1+/-1.5 42% % Inpt Reduction (Acute) 29930 +/- 6051 5329+/-474 6.6 +/- 2.8 77.9% 9307+/-1160 2993+/- 372 4.9 +/- 2.94 68% Lowertertile % Inpt Days Reduction 13505 +/- 1379 7842+/- 586 10 +/- 4.6 35.2% 7774+/- 890 5475+/- 511 9.2 +/- 4.6 9% Admits/100 Pt-M 26,134 +/- 2861 9490+/- 446 13.8 +/- 2.2 54% 10,695 +/-890 7190 +/- 397 12.2 +/-2.4 15% % Inpt Reduction (Acute) 22046 +/- 3212 7592+/-620 10.2 +/- 3.9 49% 5913+/-666 5256+/-492 8.3+/-3.9 - 12%

Factors Associated with Reduction in Inpatient Days by VA Home Based Primary Care 4.28.08

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Factors Associated with Reduction in Inpatient Days by VA Home Based Primary Care 4.28.08