The Department of Veterans Affairs prepared for the substantial rise in aging veterans by creating more geriatric-focused programs. One of them is the home-based primary care (HBPC) model.¹ Central to HBPC is the home delivery of primary care to promote health and prevent setbacks in homebound or nearly homebound veterans and to improve overall quality of life.

In the Veterans Affairs system, HBPC is not confined by the Medicare definition of homebound. HBPC services are available to all veterans who have difficulty getting transportation to veterans hospitals for many reasons.

Need for HBPC

With chronic disease climbing and the number of older veterans on an upswing, the cost of delivering healthcare to the veteran population is rising rapidly and significantly. The longer a person lives, the more likely it is that he or she will acquire comorbid chronic conditions that negatively influence quality of life and the cost of living. Illness can restrict a patient to his or her home or to an institutional living situation.

As the world around aging veterans shrinks, so may their ability to seek medical attention. Older adults who may not have resources to transport them to appointments wait so long to obtain healthcare that they often end up in emergency departments. Acutely ill older adults often require lengthy hospital stays, after which they may need rehabilitation. These are costly services that burden all taxpayers.

The Veterans Affairs healthcare system developed a method to minimize acute visits and hospitalizations by delivering care in the home. HBPC provides timely healthcare, preventive screenings and early interventions that directly reduce the overall cost of care and improve quality of life.

The Team

Each HBPC interdisciplinary team consists of a nurse practitioner or physician assistant, a registered nurse, an occupational therapist, a psychologist and a social worker. These team members visit with patients in their homes. A gerontologist, pharmacists, dietitians, program administrator and a clinical nurse manager provide additional expertise.

The entire team meets after patient admission and at defined periods to assess each patient's treatment plan. Discussions can address treatment plan adherence and psychosocial issues influencing wellness. Negative influences affecting access to care can be quickly identified so that community services can be integrated into the treatment plan, if indicated.

The clinical team members provide independent visits over time, producing more frequent opportunities for observation of patient status than the typical office visit in which the patient is seen by all disciplines on the same day.

The NP is the team leader and facilitator, providing patient assessments, facilitating the focus of care, and providing the initial problem list for the treatment plan. The team provides input into necessary monitoring and additional interventions. The gerontologist and program director serve as specialty providers. These consultations offer a valuable method to assist in assessment and early intervention to defray unnecessary emergency visits or hospitalizations. All interdisciplinary team members are available to the patient by phone.

The HBPC team members are salaried, and the absence of reimbursement concerns allows for many means of assessment other than visits. Phone consultations are often used to assess the effectiveness of treatments and are vital to providing timely communication and swift alterations in the treatment plan.

In addition to timely treatment, prevention of disease exacerbation or injurious accidents within the home is key. The nurse and NP assess medications at every visit. Overnight delivery of medications, although rarely needed, is an option for homebound veterans who require critical changes.

The team occupational therapist assesses home safety and equipment to prevent injury and promote independence. Each Veterans Affairs Medical Center provides a multitude of equipment to maintain the veteran in the home as long as possible. Veterans also have access to vision and hearing specialists to help minimize errors or accidents related to sensory loss. Transportation can be supplied to qualified recipients for specialty appointments.

Cognitive evaluations by a licensed psychologist help identify mental capacity issues that potentially impede home safety. These evaluations may assist family members in understanding the veteran's limitations and coping with his or her needs.

Success Rates

HBPC has been highly successful at saving the Department of Veterans Affairs millions of dollars annually. In the Richmond, Va., system alone, participant hospital admissions dropped from 213 to 74 between the year prior to HBPC implementation and the year following it. Our system has also recorded significantly shorter hospital stays.

Although early studies did not find the HBPC model to be a good value compared with other practice settings or in lieu of them, the Veterans Affairs version of this model has produced 5 years of statistics that prove otherwise.² Several factors must be considered in comparative terms, including the reduction in emergency visits and hospitalizations. These were not included in previous comparisons of HBPC models and traditional primary care models.

The cost to supply outpatient primary care to an average patient at the Richmond Veterans Affairs Medical Center is about $3,400 per year. For an HBPC patient, it is approximately $7,011 year. In the 12 months preceding admission to HBPC, the approximate cost to the medical center for these veterans was $4.5 million. This figure combines the total cost of inpatient stays with the cost of providing primary care services. It does not include specialty care or emergency department visits. After admission to HBPC, participant cost to the government was reduced to $3.2 million. This figure combines the cost to administer the HBPC program and the cost of inpatient hospitalizations occurring after admission to HBPC.

With an overall cost savings of almost $1.25 million annually from reduced inpatient days alone, the HBPC program more than justifies itself. By maintaining patients in their homes and out of the institutional setting, quality of life improved, patient satisfaction increased, cost to the medical center dropped, and the potential medical cost to the states for nursing home care was minimized. As found in other studies and substantiated by review of recent local, regional and national veterans health statistics, the cost of HBPC is higher per visit than outpatient primary care. But when the cost of hospital admissions is accounted for, it is a cost-effective alternative to a traditional primary care model for the homebound veteran population.

ational studies have substantiated a rebound hospitalization rate reduction of 29% and a reduction in hospital stays by 34% when HBPC models are administered.³ The national Veterans Affairs system is realizing this benefit within its own HBPC model. In a 12-month period after patients were admitted to HBPC, the nationwide system recorded a 68% reduction in the number of hospital days.

b>Putting It Into Practice

The Department of Veterans Affairs recognizes the effectiveness and financial viability of the HBPC team model. A dedicated multidisciplinary team, combined with a hospital-wide ancillary service commitment, is the foundation for a HBPC program that provides an effective means to deliver high-quality, cost-effective care to homebound or nearly homebound patients with complex comorbid illnesses.

References

1. Beales JL, Edes T. Veterans affairs home based primary care. Clin Geriatr Med. 2009;25(1):149-154.

2. Hughes SL, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

3. Okie S. Home delivery - bringing primary care to housebound elderly. N Engl J Med. 2008;359(23):2409-2412.

Bridget Vetere Kmetz is a family nurse practitioner who is a team leader in the home-based primary care program at Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Va.