Effects of Home-Based Primary Care on Hospital Use for High-Need Medicare Patients: an Observational Study.

BACKGROUND: High-need, high-cost Medicare patients can have difficulties accessing office-based primary care. Home-based primary care (HBPC) can reduce access barriers and allow a clinician to obtain valuable information not obtained during office visit, possibly leading to reductions in hospital use. OBJECTIVE: To determine whether HBPC for high-need, high-cost patients reduces hospitalizations and Medicare inpatient expenditures. DESIGN: We conducted a matched retrospective cohort study using a difference-in-differences analysis to examine patients 2 years before and 2 years after their first home visit (HBPC group). PARTICIPANTS: The study included high-need, high-cost fee-for-service Medicare patients without prior HBPC use, of which 55,303 were new HBPC recipients and 156,142 were matched comparison patients. INTERVENTION: Receipt of at least two HBPC visits and, within 6 months of the index HBPC visit, a majority of a patient's primary care visits in the home. MAIN MEASURES: Total and potentially avoidable hospitalizations and Medicare inpatient expenditures. KEY RESULTS: HBPC reduced total hospitalization rates, but the marginal effects were not statistically significant: a reduction of 11 total hospitalizations per 1000 patients in the first year (- 0.6%, p = 0.19) and 14 in the second year (- 0.7%, p = 0.16). However, HBPC reduced potentially avoidable hospitalization rates in the second year. The estimated marginal effect was a reduction of 6 potentially avoidable hospitalizations per 1000 patients in the first year (- 1.6%, p = 0.16) and 11 in the second (- 3.1%, p = 0.01). The estimated effect of HBPC was a small decrease in inpatient expenditures of $24 per patient per month (- 1.1%, p = 0.10) in the first year and $0 (0.0%, p = 0.99) in the second. CONCLUSIONS: After high-need, high-cost patients started receiving HBPC, they did not experience fewer total hospitalizations or lower inpatient spending but may have had lower rates of potentially avoidable hospitalizations after 2 years.

Digital home care interventions and quality of primary care for older adults: a scoping review.

BACKGROUND: Population aging is forcing the transformation of health care. Long-term care in the home is complex and involves complex communication with primary care services. In this scenario, the expansion of digital health has the potential to improve access to home-based primary care; however, the use of technologies can increase inequalities in access to health for an important part of the population. The aim of this study was to identify and map the uses and types of digital health interventions and their impacts on the quality of home-based primary care for older adults. METHODS: This is a broad and systematized scoping review with rigorous synthesis of knowledge directed by the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The quantitative data were analyzed through descriptive statistics, and the qualitative data were analyzed through basic qualitative content analysis, considering the organizational, relational, interpersonal and technical dimensions of care. The preliminary results were subjected to consultation with stakeholders to identify strengths and limitations, as well as potential forms of socialization. RESULTS: The mapping showed the distribution of publications in 18 countries and in the Sub-Saharan Africa region. Older adults have benefited from the use of different digital health strategies; however, this review also addresses limitations and challenges, such as the need for digital literacy and technological infrastructure. In addition to the impacts of technologies on the quality of health care. CONCLUSIONS: The review gathered priority themes for the equitable implementation of digital health, such as access to home caregivers and digital tools, importance of digital literacy and involvement of patients and their caregivers in health decisions and design of technologies, which must be prioritized to overcome limitations and challenges, focusing on improving quality of life, shorter hospitalization time and autonomy of older adults.

Adapting Measurement-Based Care to VA Home-Based Primary Care Mental Health Treatment: A Quality Improvement Project.

OBJECTIVES: This quality improvement project sought to develop guidance for Home-Based Primary Care (HPBC) Mental Health (MH) clinicians on integrating Measurement-Based Care (MBC) into their practice and gain participating psychologists' feedback on their experience using MBC for treating mental health concerns with HBPC Veterans. METHODS: Based on feedback from the HBPC MH community and in consultation with national leadership, a workgroup of HBPC psychologists developed a guide tailoring MBC to HBPC Veterans. Eight HBPC psychologists piloted the adapted MBC approach with 53 Veterans. Participating psychologists provided feedback on measure administration, Veterans' responses to MBC, and perceived benefits and challenges. RESULTS: Pilot participants' feedback suggested that MBC can be a highly useful tool for delivering mental health services in HBPC, although feedback varied about specific MBC measures. Qualitative feedback was primarily positive, but participants noted challenges based on the nature of the presenting problem and Veteran-specific characteristics. CONCLUSIONS: Findings indicate that MBC can be utilized with appropriate HBPC Veterans and has the potential to benefit care. Further research is needed to clarify factors that enhance or reduce MBC's utility within HBPC. CLINICAL IMPLICATIONS: HBPC MH providers identified MBC as a useful tool particularly when adapted to meet the needs of HBPC Veterans.

Korean primary health care program for people with disabilities: do they really want home-based primary care?

BACKGROUND: Despite many studies on home-based primary care (HBPC)-related benefits and challenges, little is known about the perspectives of potential target groups of the care and their intention or preference for using it. This study aimed to explore the demand for HBPC from the perspective of people with disabilities (PWDs) and caregivers and identify relevant determinants for that demand. METHODS: Data from the population-based survey conducted in the Gyeonggi Regional Health & Medical Center for People with Disabilities in South Korea were analyzed. Logistic regression analysis was performed to identify relevant determinants for the demand on HBPC. RESULTS: Overall, 22% of respondents required HBPC, and 34.7% of persons aged ≥ 65 years demanded it. Older adults with disability, homebound status, and a need for assistance with daily living activities were associated with a demand for HBPC. Though having severe disability, only 19.49% of self-reported respondents demanded for HBPC, while 39.57% of proxy-reported respondents demanded for HBPC. Among self-reported group, only marital status was a predictor associated with a demand for HBPC. In contrast, among proxy-reported groups, PWDs with external physical disabilities, or with unmet medical needs due to availability barriers reported a higher demand for HBPC. CONCLUSIONS: The demand for HBPC does not derive from the medical demands of the users themselves, but rather the care deficit by difficulty in getting out of the house or in outpatient care. Beyond an alternative to office-based care, HBPC needs to be considered to solve the care deficit and as well as to deal with PWDs' medical problems.

Firearm Safety and Suicide Prevention for Medically Complex Older Veterans: Perspectives of VA Home-Based Primary Care Directors and Psychologists.

OBJECTIVES: Determine strategies and resources used by VA Home-Based Primary Care (HBPC) teams to discuss firearm safety and suicide risk with older veterans and their families or caregivers. Training and resource needs for promoting firearm safety with older veterans were also ascertained. METHODS: Ten focus groups (N = 37) were conducted virtually in 2022 with HBPC directors and psychologists. Qualitative rapid response coding identified domains and themes within transcripts. RESULTS: Analysis revealed three major domains: firearm safety, suicide risk, and resources/trainings. Firearm safety themes included discussions during clinical procedures, firearm-related challenges, veteran culture, and barriers and facilitators to effective conversations. Suicide risk themes included assessment procedures, frequency/types of risk conversations, factors related to suicidal ideation/behavior, challenges, and strategies to enhance communication. Resource/training themes included those currently used and perceived needs. CONCLUSIONS: Participants described strategies for facilitating firearm safety and suicide prevention discussions with older veterans, their families, and caregivers. Using respectful language and attending to values related to firearm ownership were identified as essential. CLINICAL IMPLICATIONS: Additional clinician/staff training/resources are needed for addressing older veteran firearm safety and suicide risk, including how to conduct more effective conversations with older veterans on these topics and better engage families/caregivers in prevention efforts.

Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care.

In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings. Using a directed approach to content analysis, we identified and described how HBPC clinicians worked to build relationships with patients, experienced challenges with emotional attachment, and negotiated boundaries in the patient-clinician relationship. Our findings illustrate how the home care setting is a site for which strong, therapeutic patient-clinician relationships can be developed while also highlighting the work that clinicians must do to balance addressing patient needs stemming from social isolation and adherence to their own professional boundaries.

Problem Solving Training for Veterans with Complex Comorbidities: Treatment Delivery Adaptations during COVID-19.

OBJECTIVES: To summarize adaptations due to COVID-19 for VA Problem Solving Training (PST) for clinicians serving medically complex patients and to compare patient mental health outcomes in the year before (2019) and during COVID-19 (2020). METHODS: Clinicians attended a multi-day workshop and up to 6 months of small-group consultation for two training cases. In 2019 and 2020, 122 Veteran patients completed baseline and posttreatment measures of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7 item), and negative problem-solving beliefs (Negative Problem Orientation Questionnaire). Qualitative data were collected on clinician's pandemic-related treatment implementation challenges. RESULTS: Program adaptations during COVID-19 addressed challenges due to delivering treatment by telephone, video, or in person; Veteran patient recruitment barriers; and privacy issues for telephone and video. Veterans in both pre-pandemic and COVID-19 cohorts had significant improvements in depression, anxiety, and negative problem-solving beliefs, with no significant differences in the amount of improvement between the two cohorts. CONCLUSIONS: Flexibilities afforded to clinicians delivering the PST training program during the pandemic addressed key obstacles and barriers to recruitment, and implementation did not diminish the effectiveness of the intervention. CLINICAL IMPLICATIONS: Findings support continued implementation of the PST training program with added flexibility to treatment delivery beyond the pandemic.

Evaluation of an initiative to improve advance care planning for a home-based primary care service.

BACKGROUND: Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP. METHODS: The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation. RESULTS: We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively. CONCLUSIONS: Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.

VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans.

The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York.

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

A qualitative study of health-care experiences and challenges faced by ageing homebound adults.

BACKGROUND: The ageing of the global population is associated with an increasing prevalence of chronic diseases and functional impairments, resulting in a greater proportion of homebound individuals. OBJECTIVE: To examine the health-care experiences of older homebound adults who have not previously received home-based primary care (HBPC). To explore their impressions of this method of care. DESIGN: Cross-sectional qualitative study using semi-structured interviews. SETTING AND PARTICIPANTS: 18 older homebound individuals in Central Virginia. RESULTS: Our findings revealed that homebound individuals faced significant health challenges, including pain resulting from various comorbidities. They felt that their mobility was restricted by their physical conditions and transportation challenges. These were major barriers to social outings and health-care access. Participants left their homes infrequently and typically with assistance. Regarding office-based care, participants were concerned about long wait times and making timely appointments. Some thought that HBPC would be convenient and could result in better quality care; however, others believed that the structure of the health-care system and its focus on efficiency would not permit routine HBPC. DISCUSSION AND CONCLUSIONS: Older homebound adults in this study faced high burdens of disease, a lack of mobility and difficulty accessing quality health care. Our observations may help researchers and clinicians better understand the health-care experiences and personal opinions of older homebound individuals, informing the development of effective and empathetic home-based care. Participant responses illuminated a need for education about HBPC. We must improve health-care delivery and develop comprehensive, patient-centered HBPC to meet the needs of homebound individuals.

Evaluating the care provision of a community-based serious-illness care program via chart measures.

BACKGROUND: Although quality-of-care domains for home-based primary and palliative programs have been proposed, they have had limited testing in practice. Our aim was to evaluate the care provision in a community-based serious-illness care program, a combined home-based primary and palliative care model. METHODS: Retrospective chart review of patients in an academic community-based serious-illness care program in central North Carolina from August 2014 to March 2016 (n = 159). Chart review included demographics, health status, and operationalized measures of seven quality-of-care domains: medical assessment, care coordination, safety, quality of life, provider competency, goal attainment, and access. RESULTS: Patients were mostly women (56%) with an average age of 70 years. Patients were multi-morbid (53% ≥3 comorbidities), functionally impaired (45% had impairment in ≥2 activities of daily living) and 32% had dementia. During the study period, 31% of patients died. Chart review found high rates assessment of functional status (97%), falls (98%), and medication safety (96%). Rates of pain assessment (70%), advance directive discussions (65%), influenza vaccination (59%), and depression assessment (54% of those with a diagnosis of depression) were lower. Cognitive barriers, spiritual needs, and behavioral issues were assessed infrequently (35, 22, 21%, respectively). CONCLUSION: This study is one of the first to operationalize and examine quality-of-care measures for a community-based serious-illness care program, an emerging model for vulnerable adults. Our operationalization should not constitute validation of these measures and revealed areas for improvement; however, the community-based serious-illness care program performed well in several key quality-of-care domains. Future work is needed to validate these measures.

Who Are the People Willing to Pay for Physician Home Visits?

BACKGROUND: Since the recently announced Community Care Policy, there has been an opinion that Korea needs to establish an alternative medical model such as physician home visits. This study aimed to assess the need and willingness to pay (WTP) for physician home visits among the community-dwelling Korean older population and to determine the most important factors that influence older adults to decide to use a physician home visit service. METHODS: A total of 797 people aged 60 years or older who were randomly selected from a nationwide dataset using a multi-stage stratified sampling method answered a questionnaire on the need and WTP for physician home visits. RESULTS: A total of 39.3% of participants reported that they would like a physician home visit when they need help. Among older adults who needed physician home visits (n = 313), the WTP amount for physician home visits was 21,982 ± 17,546 KRW. Logit and Tobit regression analyses showed that the higher valuated need and WTP for physician home visits was associated with a lower level of physical/psychosocial functioning measured by EuroQol-five dimensions score (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01-1.27; P = 0.035) and a higher level of satisfaction when using community-based services such as public health centers (OR, 1.32; 95% CI, 1.02-1.72; P = 0.034), social welfare centers and Gyeong-ro-dang (OR, 1.61; 95% CI, 1.04-2.50; P = 0.033; ß = 8.39; standard error, 3.63; P = 0.021). CONCLUSION: This study provides evidence that the decision to pay for a physician home visit service is based upon the complex interactions among an individual's physical and psychosocial functioning, personal experiences of service utilization, and demographic factors. The value for physician home visits should be qualified based on the empirical data of WTP, which comes from a consumer-centered perspective.

Implementing Geographic Information Systems (GIS) into VHA Home Based Primary Care.

The Veteran's Health Administration (VHA) Home Based Primary Care (HBPC) program provides comprehensive in-home primary care services to elderly Veterans with complex chronic medical conditions. Nurses have prominent roles in HBPC including as program leaders, primary care providers and nurses who make home visits. Delivery of primary care services to patients in their homes can be challenging due to travel distances, difficult terrain, traffic, and adverse weather. Mapmaking with geographic information systems (GIS) can support optimization of resource utilization, travel efficiency, program capacity, and management during normal operations, and patient safety during disasters. This paper reports on the feasibility, acceptability and outcomes of an initiative to implement GIS mapmaking in VHA HBPC programs. A mixed method evaluation assessed extent of adoption and identified facilitators and barriers to uptake. Results indicate that GIS mapping in VHA HBPC is feasible and can increase effectiveness and efficiency of VHA HBPC nurses.

Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study.

OBJECTIVES: This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members. DESIGN: HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates. SETTING: Programs varied in setting, geographic locations, and primary care model. PARTICIPANTS: Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews. MEASUREMENTS: Recorded interviews, focus groups, and field observation notes. RESULTS: Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness. CONCLUSIONS: Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

Change in quality of life and potentially associated factors in patients receiving home-based primary care: a prospective cohort study.

BACKGROUND: The trajectories for health-related quality of life of patients receiving home-based primary care are not well identified. Our objective was to investigate changes in the quality of life (QOL) and factors that affected the QOL of patients receiving home-based primary care. METHODS: Our prospective cohort study, the Observational study of Nagoya Elderly with HOme MEdical (ONE HOME) study, recruited 184 patients undergoing home-based primary care with a 5-year follow-up period. Patients' demographic data, socioeconomic status, physical diseases, medication use, feeding intake status, nutritional status, and functional status were measured annually. The 4-item quality of life index (QOL-HC [home care]) including self-perceived and family-reported QOL ratings that had been developed and previously validated in home care settings was used. Linear regression models were used for cross-sectional and longitudinal analyses. RESULTS: The participants' mean age was 78.8 ± 10.8 years, and 55.9% of the sample was male. Most patients were frail, disabled, and/or malnourished. Self-perceived and family-reported QOL scores dropped sequentially on annual follow-ups. In the multivariate longitudinal analysis, patients who were divorced (ß = 1.74) had high baseline QOL scores (ß = 0.75) and reported higher QOL ratings. In addition, high functional dependency was associated with a low self-perceived QOL rating, with a ß-value of - 1.24 in the pre-bedridden group and - 1.39 in the bedridden group. Given the family-reported QOL rating, the baseline QOL scores (ß = 0.50) and Mini-Nutritional Assessment-Short-Form scores (ß = 0.37) were found to have positive associations with the QOL rating. CONCLUSIONS: For the disabled receiving home-based primary care, independent functional status and divorce were positively associated with better self-perceived QOL, whereas nutritional status was correlated with better family-reported QOL.

"We just get paid for 12 hours a day, but we work 24": home health aide restrictions and work related stress.

BACKGROUND: Home-bound patients in New York State requiring long-term care services have seen significant changes to their benefits due to turmoil in the Managed Long Term Care (MLTC) market. While there has been research conducted regarding the effect of MLTC challenges on beneficiaries, the impact of MLTC regulatory changes on home health aides has not been explored. METHODS: Qualitative interviews were conducted with formal caregivers, defined as paid home health aides (HHAs) (n = 13) caring for patients in a home-based primary care program in the New York City metropolitan area. HHAs were asked about their satisfaction with the home based primary care program, their own job satisfaction, and whether HHA restrictions affect their work in any way. Interviews were audio-recorded, transcribed, and analyzed. RESULTS: Two main themes emerged: (1) Pay, benefits and hours worked and (2) Concerns about patient well-being afterhours. HHAs are working more hours than they are compensated for, experience wage stagnation and loss of benefits, and experience stress related to leaving frail clients alone after their shifts end. CONCLUSIONS: HHAs experience significant job-related stress when caring for frail elderly patients at home, which may have implications for both patient care and HHA turnover. As government bodies contemplate new policy directions for long-term care programs which rely on HHAs the impact of these changes on this vulnerable workforce must be considered.

Home and community-based services coordination for homebound older adults in home-based primary care.

BACKGROUND: Medically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients. METHODS: An online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members. RESULTS: Nearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated 'most' or 'all' of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was 'difficult.' The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was 'difficult' or 'very difficult' to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05). CONCLUSIONS: Despite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies.

BACKGROUND: Home-based primary care (HBPC) is a multidisciplinary, ongoing care strategy that can provide cost-effective, in-home treatment to meet the needs of the approximately four million homebound, medically complex seniors in the U.S. Because there is no single model of HBPC that can be adopted across all types of health organizations and U.S. geographic regions, we conducted a six-site HBPC practice assessment to better understand different operation structures, common challenges, and approaches to delivering HBPC. METHODS: Six practices varying in size, care team composition and location agreed to participate. At each site we conducted unstructured interviews with key informants and directly observed practices and procedures in the field and back office. RESULTS: The aggregated case studies revealed important issues focused on team composition, patient characteristics, use of technology and urgent care delivery. Common challenges across the practices included provider retention and unmet community demand for home-based care services. Most practices, regardless of size, faced challenges around using electronic medical records (EMRs) and scheduling systems not designed for use in a mobile practice. Although many practices offered urgent care, practices varied in the methods used to provide care including the use of community paramedics and telehealth technology. CONCLUSIONS: Learnings compiled from these observations can inform other HBPC practices as to potential best practices that can be implemented in an effort to improve efficiency and scalability of HBPC so that seniors with multiple chronic conditions can receive comprehensive primary care services in their homes.

The effects of home-based primary care on Medicare costs at Spectrum Health/Priority Health (Grand Rapids, MI, USA) from 2012-present: a matched cohort study.

BACKGROUND: In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. However, there are relatively few studies of either the medical outcome effects or cost benefits of HBPC. In this paper, we examine medical cost and mortality outcomes for enrollees in the HBPC program offered by Spectrum Health/Priority Health (SH/PH), a not-for-profit integrated health care/health insurance system located in Grand Rapids, MI, USA. METHODS: We perform a concurrent matched cohort study. SH/PH HBPC enrollees during 2012-2014 are matched for prior costs, age, sex and comorbidities against controls selected from unenrolled insurance plan members. Twelve and twenty four-month medical costs are compared between HBPC participants and matched controls, overall and conditional on mortality status. Mortality rates of HBPC participants are studied on their own and in comparison to controls. RESULTS: At 12 and 24 months, in comparison to matched controls HBPC participants show higher ($2933) and lower ($8620) costs respectively. Relative costs and savings of HBPC participants are a function of short term increased costs upon entry into the program (enrollees who survive the first year cost $5866 more than controls); substantial savings at end-of-life (approximately $37,037 in savings relative to controls are realized); and the overall mortality of HBPC participants (mean residual lifespan is 37.75 months from the time of enrollment). We project the present value of lifetime medical cost savings due to enrollment in the HBPC program to be at least $14,336. CONCLUSIONS: The SH/PC HBPC program reduces healthcare costs while enabling frail elders to remain at home. Reduction in costs is obtained at end-of-life and is offset with a smaller initial increase in costs upon enrollment.