Skip to main content

A better way to care for frail patients: Independence at Home

Last week the Centers for Medicare and Medicaid Services (CMS) released a report that I think will change how geriatric palliative care will be delivered in the United States.

What is the report?
 CMS released the results from the first performance year of the Independence at Home Demonstration.  The Independence at Home Demonstration  is modeled on the Home Based Primary Care program from the Department of Veterans Affairs (VA) which brings comprehensive, longitudinal, interdisciplinary primary care into the home setting for patients with complex, chronic, disabling disease.  HPBC has been shown to improve access to care and reduce hospitalizations while also reducing total cost to both the VA and to Medicare.  Patients of HBPC report high satisfaction with access and continuity of care.  Would such care have similar results if offered to a general Medicare patient population who are not veterans??

What were the results of the first performance year of Independence at Home (IAH)?
According to CMS' analysis, all 17 participating practices improved quality in at least three of six quality domains.  Medicare beneficiaries participating in IAH had fewer readmissions within 30 days.  They had less inpatient and emergency department utilization for diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.

Independence at Home participation resulted in over $25 million in savings in the first performance year.  Given just over 8,400  Medicare beneficiaries enrolled, IAH led to an average of $3,070 savings per participating beneficiary.

Why is this important?

I recently helped care for a frail, older couple.  I took care of one patient, and a colleague cared for the partner.  'Can't you convince them to move to a nursing home,' I was asked. 'They are barely safe at home and it is getting harder and harder for them to come to the clinic.'  As my patient and I discussed the stable but complicated medical situation, the difficulties of  bathing, along with the challenges of 1950's split-level home design, my patient ended our conversation ended as she always has: 'I just want us to be together in our home of fifty years.'*

How do we make care at home viable when being at home is the fundamental goal of the patient?

The move to a nursing home would certainly be a lot easier to implement, but it is not what the patient wants.  Hospice certainly has been a key for helping people stay in home, but what do you do when the 6 month prognosis is not met?

Independence at Home is a model of care that would give my patient exactly what is wanted:  Primary care delivered in the home setting.  It is care that she deserves and given the potential total cost savings, paying for a home based primary care program seems like a wise investment.

What next?

The Independence at Home is still a demonstration.  To become an option for my patient, more time is needed to show the full value of the program.  If the IAH continues to perform like its first year, like the Home Based Primary Care program has for years, then it should become a Medicare Benefit.

For now Congress needs to authorize an extension of the demonstration project. With better quality outcomes and at a lower cost, how could Congress possibly fail to act?

by: Paul Tatum (@doctatum)

* The patient case is an amalgamation of events, and not reflective of one patient

Image from http://www.clker.com/clipart-home-love.html

Comments

Anonymous said…
I agree we need to come up with better models. We are already running out of capacity to provide assisted living, memory care and skilled care. The sheer numbers of aging baby boomers will more than likely strain the system to the utmost.

But as a caregiver for a parent with Alzheimer's, I question how feasible it is to push the model of "home is always best." The medical care is only one piece of the puzzle. There are also enormous social and practical implications involved in keeping an aging adult in their own home.

Who's doing the laundry? Preparing the meals? Ensuring there's an adequate supply of bread, milk, coffee, toilet paper? Picking up the clutter? Sorting the mail and paying the bills? Who's making sure the meds are administered each day and on time? Who's coordinating the medical appointments? Who's taking care of the invisible needs such as foot care? Who's driving then to church on Sundays? What about home maintenance - cutting the grass, changing the furnace filter and so on? What about the emotional needs - are they isolated? Lonely? Bored?

If an older adult is barely managing at home, what happens if there's something unexpected - a fall, a serious stroke, etc., that forces a move into skilled care?

Sure, there are homemaking and nonmedical senior companion services available to meet some of these needs - but it costs $$ out of pocket and many families simply aren't in a financial position to pay for it. Assuming that volunteers can step in is both ludicrous and unsustainable.

I am entirely in favor of honoring the wishes of aging family members. I would walk over burning coals for my mother. But we can't ignore the fact that keeping them in their own home until the end requires a significant family commitment. Certainly it's less costly from a primary care standpoint if you can avoid trips to the ER and unnecessary readmissions, but this is only one measure of the total cost - and frankly it barely registers on the Richter scale for most family caregivers. We're just trying to meet the daily needs without wearing ourselves down into exhaustion.

By all means, primary care at home is a model worth looking into. But it's critical to keep the whole picture in mind.

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …