The Importance of Home-based Primary
Care: Why Older Adults Need It
Campaign for Better Care Webinar
June 30, 2010
Bruce Leff, MD
Professor of Medicine
Co-Director, Elder House Call Program
Johns Hopkins University School of Medicine
Let’s Start with Leo
•
•
•
•
Frail, homebound, 89 years old
Limited mobility; walks with walker
Needs help with activities of daily living
Heart failure, lung disease, arthritis,
diabetes, hypertension, etc
• Admitted 4 times to the hospital last year
for heart failure
• Many medicines prescribed by physicians
who have not seen him in years
• Lives with frail wife who is his caregiver
The Population is Aging and Increasingly Frail
% of Older Adults Who
Need Daily Personal Care
• There are ~ 2-3 million
older adults with high
grade functional
impairment
• Will double in about 15
years
Our Current System Doesn’t Meet Leo’s Needs
• He can’t get to the office
• Uses 911 as primary care, goes to the
emergency department and is
admitted to the hospital repeatedly
• Treated as a basket of chronic
conditions rather than a person with
chronic conditions
• No continuity of care
• No attention to his quality of life
Our Health Care System is Fiscally Unwell
and Unsustainable
Chronic Conditions and Medicare Expenditures
Number of Chronic
Conditions
0
Percent of
Beneficiaries 65+
18
Percent Medicare
Expenditures
1
1
19
4
2
21
11
3
18
18
4
12
21
5
6
7
3
18
13
7+
2
22%
14
66%
Home-Based Primary Care
Key Principles of Effective Home-Based
Primary Care Practices
1. Compassionate, mobile primary care team providing
primary and acute care
2. Target the most ill older adults, focus on providing
high quality geriatric care and preventing
hospitalizations
3. State-of-the-art diagnosis and treatment in the home
4. Coordinate ALL medical and social services
5. Financially viable for providers and for society
Key Elements of the Home-Based Primary Care Model
Acute, ER,
Ambulance
Subspecialists
Radiology
Patient
Transportation,
Labs
MD/NP/SW
24/7 Team
Portable HER
Pharmacy,
Durable Medical
Equipment, IV,
Oxygen
Aides, Food,
Environment,
Legal Counsel,
Housing
Rehab, HHA,
Hospice
Additional Advantages of
Home-based Primary Care
• Provides access to health care and focuses on unique needs of
older adults
• “High touch, high tech” - portable technology expands clinical
repertoire of home based physician compared to clinic
• Seeing the patient in his / her own environment - builds trust,
improves diagnosis, develop better care plans
• House call physicians coordinate services and care better
• Better integration of caregivers into care plans
Outcomes of Home-Based Primary Care
Program
Outcome
Veterans Affairs Home-Based Primary
Care
↓ Total health care costs 24%
Highest pt satisfaction any VA program -83%
Virginia Commonwealth University
↓ Hospital costs 60%
Urban Medical Housecalls, Boston
↓ Hospital admissions 29%
↓ Hospital days 34%
University of Pennsylvania
↓ Total health care costs 50%
↓ Hospitalizations 64%
Philadelphia House Call Program for posthospital patients
↓ Hospital readmissions 50%
↓ Total health care costs $3,000 to $4,845
per pt
Elder Partnership for All Inclusive Care
(ElderPAC) at Penn
↓ Medicare hospital days 59%
↓ Medicare care costs 50%
Office Without Walls, Nevada
↓ Hospitalizations 27%
↓ Costs by $760 per patient
Indianapolis House Call program
↓ Hospitalization 44% for high risk patients
with multiple chronic diseases
Summary
• Population is aging and increasingly frail
• The current health care delivery system doesn’t
meet the needs of older, frail patients and is
very expensive
• Home-based primary care can deliver high
quality care and reduce health service utilization
and costs