Home care

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Home care

  1. 1. The Outcomes and Reimbursement in Home Care Joan Escarrabill MD Chronic Care Program– Barcelona Esquerra. Hospital Clínic (Barcelona) Ankara, November 15th 2013 1 Master Plan for Respiratory Diseases (PDMAR) & Home Respiratory Therapies Observatory (ObsTRD). FORES. Ministry of Health (Catalonia)
  2. 2. Agenda Context Home care Alternatives Outcomes 2
  3. 3. Historically, most health care was provided in the home N Engl J Med 1997;337: 1815-20. % house calls in patient–physician encounters 40 40 30 10 20 % 0.6 10 0 3 1930 1950 1980
  4. 4. Types of visits in Primary Care Home care 1% 2005 Phone contact 0% Primary Care Visits 42,000,000 41,000,000 Visit 99% 40,000,000 39,000,000 38,000,000 37,000,000 Home care 2% 36,000,000 2009 35,000,000 34,000,000 2005 2006 2007 2008 2009 Visits PC Visit 94% Phone contact 4%
  5. 5. Home care Primary Care ICS (2010) Who cares at home? Place of care 6% 3% 2% 5% 30% Mainly outof-hours 63% 91% Mainly long-term care (ATDOM) Doctors Nurses Social workers Home care support Office visits Phone calls Total number of consultations: 33.420.762 Home visits
  6. 6. Home oxygen therapy (1885) 6
  7. 7. There is no place like home There are clinical reasons to avoid hospitalization Overmedication Social isolation Adverse events In the hospital Inactivity 7
  8. 8. Different services in one place Out-of-Hours • Nursing care • Out-of-Hours Service Support from discharge • Hospital at home • Transitional care Long-term care • “Preventive” • Specialized Procedures at home • Drug administration
  9. 9. Definition: a difficult task Aten Primaria 2002;30:304-309 You can set the standards of care based on criteria Criteria Definition Duration of care Short < 15 days or long > 60 days Complexity Devices, decissions, daily life support Intensity Number of visitis per day Speed ​of response Emergencies / Support from discharge Coverage 24/7/265 vs working hours
  10. 10. Definition: a difficult task Out-ofHours Hospital at home Transitional care Long-term (ATDOM) Long-term (Specialist) Procedures Duration of care Short < 15 days < 60 days > 60 days > 60 days Days Complexity Very low Low Low Low Very high High Intensity Once High Low Once a month? Daily (twice/day?) Once a week ? Speed ​of response Same day High Low Scheduled Immediately Quick Coverage Out of working hours 24/7/365 Working hours Working hours 24/7/365 24/7/365
  11. 11. From transitional care to long-term care Primary care Acute care Hospital at home Long-term care Transitional care Rehabilitation Palliative care Specialised long-term care Home mechanical ventilation Nutrition (enteral/parenteral) Peritoneal dialysis
  12. 12. From transitional care to long-term care 1 It is often difficult to draw the line between transitional care and long-term care Primary care Long-term care Transitional care 2 Rehabilitation Palliative care Specialised long-term care It is not easy to define the role of generalist and specialist Home mechanical ventilation Nutrition (enteral/parenteral) Peritoneal dialysis
  13. 13. Evaluation of home care From Products To Number of visits Phone calls Admissions …. Services Meet the needs of patients according to local resources
  14. 14. Agenda Context Home care Alternatives Outcomes 14
  15. 15. Home care strategies 1 Home care from Primary care Post-diascharge & Hospital at home 2 3 4 Long-term & Integrated care Long-term & HMV 5 15 Palliative care
  16. 16. 1 Home care from primary care services Aten Primaria 2003;31:473-9 Main protocols Pressure ulcers End-of-life Bedridden patients Pain Main problems Lack of time Scarce social resources Poor coordination Nursing leadership
  17. 17. 2 BMJ 2005;329:315-20
  18. 18. COPD: Hospital at home 22% refuse Escarrabill J. Eur Respir J 2009; 34: 507–512
  19. 19. Hernández. Eur Resp J 2003;21:58-6. Age: 70.8 9.8 years FEV1 1.1 0.5 l. Home care Convencional Mortality (%) 4,1 6,9 Readmisions (%) 20 27,7 Visits ER 0.13 (0.43) 0.31 (0.62) 0.01 LOS hospital (days) 1.71 (2.33) 4.15 (4.1) < 0.001 16.5 47.5 < 0.001 7.5 0.03 % admissions > 3 days LOS home (days) 1.56 (1.31) Phone calls 2.33 (2-05) Satisfaction 19 3,56 (1-14) Home visits 8.0 p
  20. 20. Intervention effects Conventional tharapy Home care Cost = 38% lower in home care Hernández C. Eur Resp J 2003;21:58-6
  21. 21. 3 Eur Respir J 2006;28:123-30 Función respiratoria Co-morbilidad Problemas sociales Valoración global Integrated care Educación (autocuidado) Deshabituación tabáquica Conocimiento de la enfermedad Tratamiento inhalatorio Actividad física Signos y síntomas de alarma 21 Programa de asistencia personalizda Coodinación entre los diversos dispositivos asistenciales
  22. 22. Long-term follow up by specialists in LTOT Chnages related to home care 20 15 Chest 2001; 119:364–369 10 5 0 ER visits Admissions Home care Positive inpact of nurse/respiratory therapist + telephone + home visit LOS Control
  23. 23. 4 Chest 2005; 127:2132–2138 Benefits of “package of care”: assessment + follow up + home support Protocol
  24. 24. Eur Respir J 2010; 35: 310–316 5,4 Calls/patient/year 6% Requiered home care 25/188 no mechanical fault was identified 13 patients were either found to be unwell or required hospital admission
  25. 25. Systemaic follow-up Population: 291.500.000 25 Escarrabill J. Breathe 2009;6:37-42.
  26. 26. 26 Escarrabill J. Breathe 2009;6:37-42.
  27. 27. PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238      Grups petits de pacients. Seguiment curt Variabilitat terminológica Diferents intervencions Orientats a malalties – poc holístic 27 No queda clar si els efectes es relacionan amb la telemonitorització (e-Health) o amb el canvi d’estratègia assistencial
  28. 28. PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238 “Digital Health Divide” Hi ha grups de pacients que no estan prou representats en els estudis:     28 Multimobilitat Trastorns cognitius Problemes socials Discapacitats
  29. 29. Pinnok et al. BMJ 2013;347:f6070 doi: 10.1136/bmj.f6070 Risc d’ingrés 29
  30. 30. Journal of Telemedicine and Telecare 2012; 18: 211–220
  31. 31. 5 Gómez-Batiste X et al. J Pain Symptom Manage 2010;40:652-60 Home care support teams
  32. 32. Gómez-Batiste X et al. J Pain Symptom Manage 2006;31:522-32 Health Care Interventions 3% 9% 34% 26% 14% n=395 32 Home visits Hospital admission GP Visit 14% Phone call Outpatient clinic Others
  33. 33. Agenda Context Home care Alternatives Outcomes 33
  34. 34. NEJM 2010;363:2477-81 Value 34 = Outcomes Cost
  35. 35. The Outcome Measures Hierarchy. NEJM 2010;363:2477-81 • Time to recovery. • Desutilities • Sustainability of health • Long-term consequences
  36. 36. Focus on results Some mistakes can be made speaking of results 1 Believe that the results of the pilot studies can be extrapolated automatically 2 The results must to be good in the full process 3 Average approach is harmful 4 The time, from the point of view of patients, is not process is a key result.
  37. 37. Home care evaluation Health System Sustainability Population Impact Specific program Coverage Specific objectives Patient Patient experience Health results 37
  38. 38. NEJM 2013;368:201-3 38
  39. 39. Patient experience (i) Time Resolution capability Co-participation Information 39 • Waiting • Response • Resolution • How many professionals are involved to solve the problems? • Several options • Decission-making process • Deliberation • Intelligible • At the right time
  40. 40. Patient experience (ii) Utility Interference Benefit Maintenance 40 • How much was useful… • Inconveniences that generated the activity in their daily lives • Will the benefits outweigh the drawbacks? • To what extent it will be possible to maintain ....?
  41. 41. Indicators • Admission • Readmission • Visits • Age/gender • Diagnostic • Comorbidity Transitions and contacts Care cycle • Resolution • Hospital days/yerar 41 Demography Mortality • Intra-hosp
  42. 42. BMJ 2012;345:e6017 42
  43. 43. BMJ 2012;345:e6017 43
  44. 44. The paradox of "pilot studies" Pilot studies Real life
  45. 45. 43% 32% Eur J Cardiovasc Nurs. 2011 Mar 12.
  46. 46. “Value-based purchasing” The value is measured by considering the "whole process" not every "individual procedures"
  47. 47. Standardization Març 2009 … and health professionals (mainly physicians) they prefer the arts to science
  48. 48. 48 JAMA 2013;309:355-363
  49. 49. Ann Intern Med. 2010;153:167-175.

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