Understanding and Improving the Burden and Unmet Needs of Informal Caregivers of Homebound Patients Enrolled in a Home-Based Primary Care Program.

The growing homebound population is heavily reliant on informal caregivers, who are increasingly burdened by their roles. This study describes informal caregivers of the homebound who remain caregivers at a 9-month follow-up and examines the impact of a home-based primary care (HBPC) program on caregiver burden and unmet needs using a prospective design with a pre-post intervention assessment. Informal caregivers of the urban homebound are similar to caregivers of other populations and have a broad range of unmet needs. The intervention described is the regular provision of multidisciplinary HBPC. Hundred fourteen caregivers of newly admitted patients complete a baseline interview. For the 56 caregivers who complete a 9-month follow-up interview, participation in HBPC is associated with a statistically significant decrease in overall caregiver burden. At 9 months, caregivers demonstrate an overall decrease in unmet needs, with a statistically significant decrease across two measured domains. These results suggest that the regular provision of multidisciplinary care in the home can mitigate the deleterious impact of informal caregiving.

The positive financial contribution of home-based primary care programs: the case of the Mount Sinai Visiting Doctors.

The coming decade will see a rise in the number of homebound seniors. These vulnerable patients have great difficulty accessing primary care. Home-based primary care (HBPC) can fill this healthcare need. Presently, such programs have been slow to develop, in part because of the perception that they are fiscal liabilities. Using the Mount Sinai Visiting Doctors (MSVD) program, the total financial effect of an HBPC program on an Academic Health Center (AHC) was assessed. A retrospective cohort analysis (n=692, 565 patient years) of Medicare-eligible individuals who were enrolled in the MSVD HBPC program was conducted. Revenues and associated costs for direct physician home care services, inpatient admissions, and outpatient clinic and emergency department visits for 1 calendar year were captured. Sensitivity analyses varying efficiency and cost variables were performed. Total direct cost for HBPC for the patient cohort was $976,350. Direct billing from home visits generated revenues that covered 24% of total direct care costs. Over a 12-month period, the cohort had 398 inpatient admissions and 1,100 non-HBPC outpatient visits, generating an overall contribution to margin of nearly $2.6 million. It is likely that this analysis underestimates the true contribution to margin, because it does not capture patient encounters at specialty clinics not in the Department of Medicine, unaffiliated medical centers, or private community-based practices. Although direct billing for HBPC programs does not generate enough revenue to meet operating costs, they can be significant revenue generators for the wider healthcare system and thus are fiscally worthy of subsidization.

Brief communication: National quality-of-care standards in home-based primary care.

BACKGROUND: Home-based primary care for homebound seniors is complex, and practice constraints are unique. No quality-of-care standards exist. OBJECTIVE: To identify process quality indicators that are essential to high-quality, home-based primary care. DESIGN: An expert development panel reviewed established and new quality indicators for applicability to home-based primary care. A separate national evaluation panel used a modified Delphi process to rate the validity and importance of the potential quality indicators. PARTICIPANTS: Two national panels whose members varied in practice type, location, and setting. RESULTS: The panels considered 260 quality indicators and endorsed 200 quality indicators that cover 23 geriatric conditions. Twenty-one (10.5%) quality indicators were newly created, 52 (26%) were modified, and 127 (63.5%) were unchanged. The quality indicators have decreased emphasis on interventions and have placed greater emphasis on quality of life. LIMITATIONS: The quality indicator set may not apply to all homebound seniors and might be difficult to implement for a typical home-based primary care program. CONCLUSIONS: The quality indicator set provides a comprehensive home-based primary care quality framework and will allow for future comparative research. Provision of these evidence-based measures could improve patient quality of life and longevity.

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward.

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

Medication utilization in an urban homebound population.

BACKGROUND: The number of medically homebound adults has grown with the aging of the U.S. population, yet little is known about their health care utilization. We sought to characterize the health status and medication utilization of an urban cohort of homebound adults and to identify factors associated with medication use in this population. METHODS: We performed a retrospective cross-sectional analysis of 415 patients enrolled in a primary care program for homebound adults in New York City during October 2002. Numbers of medications were obtained from formularies corroborated by home visits. For patients without prescription insurance, medication out-of-pocket costs were estimated according to average wholesale pricing. Sociodemographic and disease characteristics were obtained by chart abstraction. RESULTS: The median age was 83 years (range 25-106 years). Seventy-seven percent of patients were female, 63% were non-white, and 28% spoke Spanish. Sixty-four percent of patients had Medicaid. The cohort had a mean of 8.2 (range 1-27, standard deviation 4.5) medications prescribed per month. Multivariate analysis showed that increasing age was associated with fewer medications (p <.001). Charlson comorbidity score was positively associated with number of medications (p <.001), whereas Activities of Daily Living score, a measure of functional dependence, was not. Twenty-seven percent of the cohort lacked prescription drug coverage. The total number of medications per month among the uninsured patients was 7.4 (standard deviation 4.4). Estimated median monthly out-of-pocket cost for the uninsured patients was dollar 223 (range dollar 1-dollar 1512). CONCLUSIONS: For homebound patients without prescription drug coverage, medication use may represent substantial financial burden. Additional research is needed to determine whether out-of-pocket medication costs represent a barrier to care in this population.

Home care of the frail elderly.

Statistics indicate that as the population ages, there will be an increased need for home care. Despite this increased need and the legal, clinical, and ethical obligations for physicians to participate, little training is available to physicians in the area of home care. This article provides physicians with an understanding of home care and how to incorporate it into clinical practice. The goals of this article are to (1) explain what home care is and what services are available, (2) teach physicians how to access these services and oversee their implementation, and (3) show how physicians can be reimbursed for this increasingly important part of their practice.

Using focus groups to identify asthma care and education issues for elderly urban-dwelling minority individuals.

A growing number of older adults are afflicted with asthma; these older asthmatic individuals suffer more deleterious consequences as compared with younger asthmatic individuals. Asthma is a chronic condition requiring the person's ability to self-manage symptoms. Few educational programs have focused on older asthmatic adults' learning needs and even fewer on those of older minority individuals with this disease. Three focus groups were conducted in East Harlem. Each group consisted of 6 to 10 participants. All focus groups were led by the same co-leaders and were conducted using the same semistructured format. Discussions were audio-taped and transcribed. Transcriptions were reviewed by two independent raters who determined major themes and concerns. Comparisons were made and discrepancies resolved through discussion and consensus with the team of investigators. In this pilot study, there were important similarities in the themes identified by participants in the 3 focus groups. Older individuals with asthma, their unlicensed caregivers, and health professionals all identified the following as important in the care of older adults who are asthmatic: (1) the negative impact of asthma on the individual's quality of life, (2) high cost of medications, (3) nonadherence to the medical regimen, and (4) difficulty that these individuals have in accessing the health care system.

The determinants of attitudinal change among medical students participating in home care training: a multi-center study.

PURPOSE: To report attitudinal changes of medical students from five medical schools rotating through a home care program, and to determine which of the program characteristics influenced attitudes the most. METHOD: A survey instrument covering four home care domains (general attitudes, home-based therapies, home care training, and time and reimbursement) was designed and validated by the five schools involved. Using pre- and post-rotation scores, analyses were done to evaluate for attitudinal changes within and among schools. The programs had similar basic characteristics (home visits, attending physicians' involvement, didactics), but had differing degrees of these components. RESULTS: Significant improvements in attitude scores were found in three domains: general attitudes, homebased therapies, and home care training. For time and reimbursement, only three schools improved significantly between pre- and post-rotation scores. Among the five schools, there were significant differences in the homebased therapies and home care training domains (p <.05), and in the time and reimbursement domain the difference approached significance (p =.06). None of the students' characteristics but all of the programs' characteristics significantly correlated with changes in total scores. In the first multiple regression model, educational level (third year instead of fourth) was the only independent predictor of change in score, (adjusted r(2) =.14). In Model 2, the strongest predictor was "contact with physician-program director," followed by "number of visits" and "physician-precepted visits" (r(2) =.23). CONCLUSION: Educational home care programs of varying intensities can positively affect medical students' attitudes towards home care. At least three program characteristics, (the physician-program director, number of visits, and physician-precepted home visits), are important parts of a successful program.