How IAH House Call Model Works Campaign for

How IAH House Call Model Works Campaign for Better Care Webinar June 30, 2010 K. Eric De Jonge, M. D. Washington Hospital Center Washington D. C.

Case – Ms. Alma • 2007 - 96 yo woman, in wheelchair, with breast/axillary mass, left arm blood clot • No doctor in 10 years • Uncontrolled HTN, DM, Severe Arthritis • Dx: Regionally metastatic Breast CA • Rx: Femara, Coumadin, BP meds, PT

Ms. Alma • 2007 -2009 - Home-Base Primary Care – Arrange aides, rehab, INR, meds / DME – 31 medical house calls, 23 SW visits – 2 admissions to WHC • 8/08 - MRSA arm abscess, LOS – 2 days • 2/09 - MRSA gangrene AKA, LOS- 15 days Goes home very ill, with hospice, 16 -hour aides and family • Course: Sacral ulcer, infected AKA suture, dysphagia, weight loss,

Usual Care? • Transport to ER/Office as crises occur • Default - Full Code status / life support • Progression of functional decline, pressure sore, infected AKA, Dysphagia tests • Multiple admissions, ICU? , NHP

Ms. Alma – Goals with MHCP team • “Stay home” with comfort and safety • Allow Natural Death (AND) – Intensive coordination: • Acute care, Oncology, Vascular, Optho, Rehab, Hospice, Meds, DME, Aides, Family support – 10/09 - Still home after 2 years, now bedbound • Great Spirit -- “And how are you doing? ”

Key Elements • Focus on 10% most ill elders = >60% of $$ – “Too sick to go to the office” • Mobile MD/ NP/ SW primary care team – About 300 patients per team • Full responsibility over all settings, until end of life

Independence at Home: Patients • 2 or more severe chronic illnesses, plus • Functional impairment in 2 or more ADLs, plus • Hospitalization and post-acute care (rehab or home care) in the past 12 months

Core Staff Roles • MD- Initial visit, hospital care, complex Dx / Rx • NP- Follow-ups, Urgent visits, education • SW- Case mgt. supportive services / counseling • Coordinator: Deliver all services and transport

Spokes of Wheel • • Acute / ER care Pharmacy / DME delivery Personal Care aides IP rehab Skilled home care (RN/ rehab) APS/ Legal Hospice Specialty MD / Radiology services

Perspectives- Three Legs Mobile Primary Care Community Resources & Supportive Services Environment Support Functional Independence

Weaknesses of HBPC • Staff and time-intensive – Premium on geography, mobile EHR with interoperability across settings • Finding and paying good MDs well • Hard to innovate inside large organizations • Now-- Need secondary revenue to be viable – HHA, hospice, labs, Radiology, Philanthropy

Strengths • Trust clear goals, alliance at EOL • Prevent dangerous and high-cost events – Savings for Medicare, share with providers • Model for health reform that works – - High-cost elders