Home Based Primary Care
Bridging the gap for chronic palliation between
restorative care and end of life care
JHLC – Geria...
Home Based Primary Care
The American Academy of Home Care Physicians (aahcp.org)


For the period of year 2000-2030 the number of Americans with
...
What Patients Value


Personalized Care



Access to their Physicians



Autonomy to make Decisions



Continuity of C...
The Merry Go Round


Acute Exacerbation of Chronic Illness



ER evaluation and Hospital Admission



3 Day Length of S...
Factors Affecting Re-Hospitalization Rates


NEJM 2009 – Medicare Beneficiaries


90% of rehospitalizations within 30day...
Policy Initiatives for Primary Care


PPACA – Expanded coverage, expanded costs



Primary care focused on symptom mana...
The House Calls Model


Focused upon the sickest, most frail high cost beneficiaries



Superior access to Primary Medic...
Payer Models for House Call Programs


Medicare



Primary Care Bonus





Fee for service rates above office visits
...
Outlook for Growth


Huge unmet need (10,000 Americans age in to Medicare daily)



Patients value this model



Payers...
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Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care

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2014 Jewish Home Lifecare Palliative Care Conference: It's Not the Place, It's the Practice

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Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care

  1. 1. Home Based Primary Care Bridging the gap for chronic palliation between restorative care and end of life care JHLC – Geriatric Palliative Care conference November 12, 2013 Andrew Lyons, MD Medical Director
  2. 2. Home Based Primary Care
  3. 3. The American Academy of Home Care Physicians (aahcp.org)  For the period of year 2000-2030 the number of Americans with chronic conditions will increase by 37%  125 million to 171 million individuals  Costs associated with Care of Chronic Illness will rise exponentially  High cost, chronically ill beneficiaries   Fill an average of 20 different prescriptions per year  Account for 76% of all Hospital Admissions   See an average of seven different Physicians per year Are 100 times more likely to have a preventable hospitalization compared with a non chronically ill population A small percentage of Medicare Fee for Service Beneficiaries consume the majority of costs    Top 7% - 53%, Next 5% - 16%, Next 12% - 17% In aggregate, the top 24% consume 84% of costs 80% of Medicare Spending is for people with 4+ Chronic Illnesses 3
  4. 4. What Patients Value  Personalized Care  Access to their Physicians  Autonomy to make Decisions  Continuity of Care  ER and Hospital Avoidance  Advanced Directives for Medical Care  Relief from worry  Protection from catastrophic costs  Chronically ill patients are not price sensitive consumers 4
  5. 5. The Merry Go Round  Acute Exacerbation of Chronic Illness  ER evaluation and Hospital Admission  3 Day Length of Stay qualifies patient for “post acute” care  Sub Acute Rehabilitation Stay (restorative?)  Non Physician Home Care Services  Primary Care Provider awaits patient back in office  Chronic Illness Persists  Acute Exacerbation of Chronic Illness  “Sicker and quicker” discharges  Hospital directive to reduce LOS, adhere to DRG period  Care Transitions between Hospitalist and PCP  Treatment initiated as Inpatient not complete  Need for restorative rehab services arises  Need for supportive care is identified 5
  6. 6. Factors Affecting Re-Hospitalization Rates  NEJM 2009 – Medicare Beneficiaries  90% of rehospitalizations within 30days are unplanned  Targeted interventions at time of discharge are superior to relying upon community resources  Hospital and MD collaboration is essential  Post surgical patients benefit from Medical coordination prior to procedure  Wide State to State variability  Lack of follow up with PCP in majority of cases  Medication reconciliation requires a prescriber engaged in the care of the patient  Home Care services work best with PCP cooperation and support  Post Acute Care period is great opportunity to establish Advanced Directives  NYS has earned distinction for readmissions 6
  7. 7. Policy Initiatives for Primary Care  PPACA – Expanded coverage, expanded costs   Primary care focused on symptom management   Primary care focused on Prevention Evidence based treatment and outcomes HIT incentives    EMR subsidies for MU certified systems ePrescribing incentives and penalties Accountable Care Organizations    Lump sum payment and incentives tied to outcomes Adherence to “quality” measures Medical Home Model    Primary Care Development Corporation National Committee on Quality Assurance (NCQA) Primary Care Incentives  10% bonus for primary care E&M codes and HPSA bonuses  Loan forgiveness – serving at FQHC sites  G code/CPT Codes for Transitional Care Coordination 7
  8. 8. The House Calls Model  Focused upon the sickest, most frail high cost beneficiaries  Superior access to Primary Medical Care  Proper engagement with necessary Home Care entities  Preferred care for the patients, consistent with their values  Low cost compared with the Merry go Round  Delivers appropriate care without imposing tone of austerity  Only effective way to deliver appropriate Transitional Care  Prescriber becomes the care coordinator  Lab, xray, ultrasound diagnostic services in the home  Point of care lab services in the home  The Primary Care of the Future because it retains what was good about the past.  Data from VA program over 40 yrs has been used to influence recent CMS pilot studies: 24% reduction in overall costs, 62% reduction in inpatient days http://www.iahnow.com/IAHcostsavings.htm 8
  9. 9. Payer Models for House Call Programs  Medicare   Primary Care Bonus   Fee for service rates above office visits Home Care Certification and Care Plan Oversight Independence at Home – “Medical Home at Home”   Care Coordination Fee and Gain Sharing   2012 Demonstration Project (PPACA) Separate and apart from ACO concept Medicaid   Primary Care fees scheduled to rise under PPACA to Medicare rates Managed Care  Medicare Advantage  Dual Eligible Special Needs Plans (ISNP’s, IESNP’s)    HCC Scores, HEDIS Measures, STAR ratings Capitation Concierge Private Pay  Retainer based + Out of Network Insurance 9
  10. 10. Outlook for Growth  Huge unmet need (10,000 Americans age in to Medicare daily)  Patients value this model  Payers are beginning to value this model   Central planning and care management can be enhanced   Only for high cost beneficiaries or initial HCC risk scores Complexity of conditions requires longitudinal intervention Hospitals may value this model   Part of strategy to avoid readmission and for ER decompression Home Care companies do value this model  An engaged PCP is frequently missing from their care model  The House Call PCP helps their model work better  No comparable program for Primary Care access and cost containment exists  Government payers are supporting this model   House Call E&M codes qualify as Primary Care Will require infrastructure support to maintain standards for quality and outcomes measures (safe harbor partnerships?) 10

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