House Calls 101 Caroline A Knight MD CCFP FCFP Community Family Physician Community Preceptor, Department of Family Medicine University of Ottawa Caroline.knight@rogers.com Conflicts None Faculty/Presenter Disclosure • Faculty: Caroline A Knight MD CCFP FCFP • Program: 51st Annual Scientific Assembly • Relationships with commercial interests: – – – – Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: I am not a hospital employee Disclosure of Commercial Support • This program has received no financial support from any organization , except anticipated speaker’s honorarium from OCFP • This program has received in-kind support from OCFP in the form of one day’s free registration for this ASA, reimbursement of economy travel, one night’s hotel accommodation. • Potential for conflict(s) of interest: – None Mitigating Potential Bias Not applicable Introductions Name, what kind of HCP are you? Where do you practice, type of practice, nonenrolled/FHG/FHO/FHT/Community Health Centre ... What is your experience of house calls? Have you ever done a house call? Have you ever received any training in house calls Why are you here? What do you want to get out of this workshop? Learning Objectives What is home-based primary care? Where? Why do house calls? Current practice Who - which patients to see When to do house calls How - some practical tips How much? Getting paid Any other questions? The next step By the end of the workshop, identify at least one patient in your practice who would likely benefit from a house call. Make a commitment to do one or more house calls in the next 4 weeks. Exchange email address with a partner to debrief after doing a house call. Please send me a copy of the emails too! What is a house call? Home based primary care vs. other home care models N Stall, M Nowaczynski, S Sinha. Back to the future: home based primary care for older homebound Canadians. Canadian Family Physician (50) 237-240 March 2013 http://www.cfp.ca/content/59/3/237/T1.expansion.html 5 home-based care models 1. Skilled Home Care Functional Model: targeted nursing, allied health, social services Focus on remediable conditions, supporting independent living Time course: time limited or ongoing Personnel: nursing and allied health professionals Goals of Care: Support independent living 2. Transitional Home Care Functional Model: Medical care after hospital discharge Care focus: often disease specific e.g. CHF, COPD ... Time Course: Time limited to a designated period after discharge Personnel: FP/GPs, nurses, allied health professionals Goals of care: Prevent adverse outcomes after hospital discharge, improve coordination and continuity of care, reduce readmissions. Reduce overall costs of care 3. Hospital-at-Home Functional Model: Acute medical care in the home Care focus: Acute illness or exacerbation of chronic disease Time course: time-limited to the end of an acute episode Personnel: FP/GP, specialists, nurses, allied health professionals Goals of Care: Substitute for acute hospital care. Reduce iatrogenic events (nosocomial infection, functional decline, pressure sores, delirium, falls, etc). Reduce overall cost of care 4. Outreach Home Visits Functional Model: Home-based multidimensional geriatric assessment Care Focus: Needs assessment Time Course: Consultation with possible limited follow-up Personnel: Varied - typically nursing, allied health professionals Goals of Care: Assess needs and develop care plan to be implemented by office-based PCP or specialist 5. Home Based Primary Care Functional Model: Ongoing, comprehensive primary care in the home Care focus: Complex and interrelated chronic disease management and social care issues Time course: Ongoing Personnel: Primary care provider-led inter-professional teams Goals of care: Improve access to primary care. Maximize independence and function. Reduce ER, hospital and LTC admissions. Enhance patient safety and quality of life. Link with supportive/skilled home care services Where? OHIP Schedule of Benefits: Home: “patient’s place of residence including a multiple resident dwelling or single location that shares a common external building entrance or lobby, such as an apartment block, rest or retirement home, commercial hotel, motel or boarding house, university or boarding school residence, hostel, correctional facility, or group home and other than a hospital or Long-Term Care institution” Why do house calls? The/my pragmatic answers: How else are patients who can’t/won’t/don’t come to the office going to receive primary care? “For patients who are particularly frail or have severe mobility impairment, coordinating and executing a physician’s office visit often carries both a financial price and substantial discomfort. ... For patients with dementia or psychiatric disorders ... leaving home for a clinic visit may trigger psychological distress, and patients may simply refuse”. (Kao 2009) Why do house calls? Rapid psychosocial assessment 0f patient and their living situation - who’s at home, what is the living situation, is there food in the fridge, do they have/take meds ... which ones? Teaching learners Introduce other care providers Change of pace from the office Generate revenue outside the office Why do Housecalls? The academic answer ... what does the literature say? Do house calls make a difference - is home based primary care effective? Why do house calls? Stall, Nowaczynski, Sinha 5 English-language systematic reviews of home-based care models for the elderly ... conflicting results “Some ... home visit outreach and PC programs did not affect mortality, physical and psychosocial function, health status, health care use and costs ... other reviews concluded ... reduced mortality, admissions to LTC, functional decline”. Studies are heterogenous, many not aimed at provision of comprehensive ongoing primary care UK and Europe - patients maintain office based PCPs, home visits were separate and independent interventions Studies do not address access to PC for the homebound and fragmentation of care Why do house calls? Stall, Nowaczynski, Sinha “Learning from the US” Home-based primary care programs - “the most successful provider of h0me-based primary care has been the Veterans Health Administration” medical house calls by ongoing PCP (MD or NP) PCP leads an inter-professional care team program is available after hours for urgent issues. +/- access to home-based lab and diagnostic imaging services. Why do house calls? Stall, Nowaczynski, Sinha 8 studies 2000 - 2012 4 observational (104-468 patients) - inc. one Canadian study 3 retrospective reviews (179 - 20,783 patients) one multi-site randomized RCT (981/985 patients) 1 - 7 years Why do house calls? Stall, Nowaczynski, Sinha ED visits (4/8) - no difference to 48% decrease Hospital Admissions (8/8) - 8 - 84% decrease. RCT no difference, but 22% decrease for severely disabled (p=0.03) LTC admissions (2/8) - 10- 20% decrease Why do house calls May reduce ER use May reduce hospital admissions (especially in the severely disabled) May reduce LTC admissions Ontario government has promised $60million annually to support expansion of MD house call services to frail homebound elderly House call myths It’s too time consuming It doesn’t pay It’s not safe “Good medicine” can only be done in clinics and hospitals Who needs a housecall? Anyone who can’t, shouldn’t (or won’t) come to the office frail elderly with mobility, support or transportation problems dementia infection control e.g. immune suppression, VRE positive, 4 children with chickenpox palliative care post-natal visits for overwhelmed moms, multiple births MD should decide to whom to offer house calls based on NEED, not want. National Physicians Survey 2007, 2010 National Physicians Survey - 2007, 2010 National Physicians Survey 2007, 2010 National Physicians Survey 2007, 2010 National Physicians Survey 2007 and 2010 National Physicians Survey 2007, 2010 When to do housecalls - time management tips do the occasional house call - before or after the office, lunchtime schedule a regular time for house calls - works well in shared offices, or if the office is closed. timing - expect to take 30 - 60 minutes (sometimes longer). Avoid mealtimes for retirement home residents. How to do a housecall some practical tips Safety What to take with you Charting options What to do on a house call Safety Know as much as you can about the patient ahead of time Who else is in the home? Pets? Which entrance to use, entry phone ring number. Carry a cellphone Don’t go anywhere that you don’t feel safe - go as a team, or (in extreme) ask for police escort. Consider chaperone (family member or team member/home care nurse etc) Let someone know where you’re going - appointment schedule Safety Parking Items in car Street safety Safety In home hazards Slipping and tripping hazards Pets Aggressive family members, neighbours, other occupants of apartment buildings Smokers Infection control Home cooking Cockroaches and bed bugs Safety - avoiding hitchhiking bed bugs http://www.toronto.ca/health/bedbugs/pdf/avoidingbedbughitchhikers.pdf http://www.ottawainnercityhealth.ca/uploads/files/Documents/Policies/Wo odGreen_Bed_Bug_Manual_2008.pdf Safety - avoiding hitchhiking bed bugs Scrubs or work clothes. Wash clothing in hot water , 20 - 60 minutes in dryer ... or freezer x 2 weeks Do not remove shoes, wear disposable booties over shoes Avoid pants with cuffs and open toed shoes Consider wearing boots and/or tucking pant legs into socks. Only bring items that are needed to provide care in a sealable plastic container Avoid setting bag/bin on upholstered furniture, bedding, or carpeted floors, use disposable protective pad, or white garbage bag under bag Avoid sitting on or touching furniture, leaning on walls, or handling bedding unless needed Avoid upholstered chairs; choose a plastic or metal chair and visually inspect before sitting down, or bring collapsible metal stool Spray or wipe down any equipment used (and hands and soles of shoes) with alcohol What to Take With You Charting Paper chart is still fastest. If you use records in portable electronic form, they should be encrypted (CPSO). Be aware of security issues with remote access. What can you do on a house call? “The medicine’s the same as in the office” Examining a patient at home may require a little ingenuity sit on the floor, patient lies on sofa (or bed). Minor procedures - immunizations, joint injections, ear syringing (therapeutic peritoneal tap, sutures). Needs preplanning and bring equipment with you. My approach to a house call call ahead to schedule visit (and presence of caregivers) bathroom and kitchen check (wash hands) where to visit - living room, kitchen, bedroom the usual medical visit check all the lotions, potions, pills and puffers. tripping hazards and mobility aides caregivers/family - who are they, caregiver support, what are their questions, concerns. Elder abuse? What to do on a house call INHOMESSS (BK Unwin, PE Tatum Am Fam Physician. 2011;83(8):925-931) Impairments/immobility Nutritional status and eating habits Home environment Other people Medications Examination Safety Spiritual health/cultural and ethnic influences Services NB This is an encyclopedic approach ... don’t expect to do everything every time! INHOMESSS Impairment/immobility Evidence of cognitive impairment Demonstration of ADLS (basic, instrumental and advanced) Balance and gait Sensory impairment (hearing, vision, taste, smell, tactile) Falls? INHOMESSS Nutritional status and eating habits check kitchen, foods available nutritional status fluid intake alcohol swallowing difficulties oral health INHOMESS Home environment Neighbourhood Exterior of home Interior - crowding, good housekeeping, hominess, privacy, pets, books, TV, memorabilia, telephone, personal alarm, internet INHOMESSS Other people Caregiver(s) Caregiver issues - hours per day, stress, coping, abuse, need for respite, is the caregiver capable? Social supports Advanced Directives Powers of Attorney INHOMESSS Medication Prescription Non-prescription Dietary supplements Medication organization, compliance, discrepancy Multiple prescribers Allergies Written instructions INHOMESSS Examination Weight, Height, BP Glucose, urinalysis Montreal Cognitive Assessment Depression Screen General physical condition Focused examination INHOMESSS Safety access to emergency services adaptations to home telephone, personal alarm bathroom, kitchen carpets, lighting, cords, stairs, furniture fire and smoke detectors, fire extinguishers emergency plans, evacuation route heat, air conditioning water source (esp. rural), hot water temperature firearms Pets INHOMESSS Spiritual health, cultural and ethnic influences Services - Home care, MOW, social services, transportation, equipment Other resources to assist with care at home CCAC - case management, ongoing support with ADLS e.g. PSW for bathing, dressing, some meals. CCAC - episodic focussed care e.g. nursing for IV antibiotics, wound management, palliative care. OT, PT. In home phlebotomy and EKG - Gamma Dynacare (?? others). Cost: $30.00 for home visit - not covered by OHIP Other resources to assist with care at home CHC Primary Care Outreach to Seniors - nursing visits for ongoing monitoring, patient teaching Geriatric Community Mental Health - in home mental health support (in Ottawa mostly psychiatric nurses, social workers, one Psychiatrist) Geriatric Outreach and Assessment Teams - in- home Geriatric Assessment Alzheimer’s Society (First Link), Arthritis Society, CNIB, Parkinson’s Society, Cancer Society, ... various Senior Support organizations - Consult your Directory of Community Services, CCAC case manager How much - getting paid (in Ontario) OHIP Schedule of Benefits A901 - House call assessment (first patient seen) - $45.15 A900 - Complex house call Assessment (new - 2013) $45.15 A902 - Pronouncement of Death in the home PLUS PREMIUMS How much - Getting paid (in Ontario) (A900 Complex house call assessment - OHIP SOB A3) A complex house call assessment is a primary care service rendered in a patient’s home for a patient that is considered either a frail elderly patient or a housebound patient. The service must satisfy at a minimum, all of the requirements of an intermediate assessment Only for the first person seen during a single visit to the same location Frail elderly patient 65 years or more with one or more of Complex medical management needs Poly pharmacy Cognitive impairment e.g. dementia or delerium age-related reduced mobility or falls unexplained functional decline NOS How much - Getting paid (in Ontario) (A900 Complex house call assessment - OHIP SOB A3) Housebound patient: the person has difficulty accessing office-based primary health care services because of medical, physical, cognitive or psychosocial needs/conditions transportation and other strategies to remedy the access difficulties have been considered but are not available or not appropriate in the person’s circumstances the person’s care and support requirements can be effectively delivered at home How much - Getting Paid (in Ontario) - Special Visit Premiums max. travel Travel Premium ($36.40) Code Value Time max. patients B990 $27.50 Daytime Mon-Fri (07:00 - 17:00)/Elective Home Visit 10 2 B960 B992 $44.00 Sacrifice Office Hours 10 2 B961 B994 $66.00 Evenings Mon-Fri (17:00-24:00) 10 2 B962 B993 $82.50 Saturday, Sunday, Holiday (07:00 - 24:00) 20 6 B963 B996 $110.00 Night (00:00 - 07:00) no limit no limit B964 How Much - Getting paid in Ontario Primary care models Fee for service, Comprehensive Care Model and FHG payment as fee for service Family Health Network(FHN) - House calls are OUT of basket Family Health Organization (FHO) - House calls and special visit premiums are IN basket, but travel premiums are OUT of basket How Much - Getting paid in Ontario House Call Bonuses and Premiums - FHG, FHN, FHO Bonus level (per year) A 3 or more patients served B C D 6 or more patients 17 or more patients 32 or more patients served served served And 12 or more encounters 24 or more encounters 68 or more encounters 128 or more encounters Bonus payment $1500 $3000 $5000 $8000 PLUS 20% premium on value of claims for house call visits in excess of level C if at least 75% house calls are A900 (Complex house call) No bonus or premium for FFS, CCM Billing Example • • • • • • • • • • Pre-arranged house call to 75 year old patient with dementia (and ear wax) on Monday morning, A900 Complex house call 45.15 B990 Elective special visit 27.50 B960 Daytime travel 36.40 G420 Ear syringing 11.25 G590 Flu shot 4.50 ... and check on spouse’s BP, diabetes, and give another flu shot K030 Diabetic Management Assessment 39.20 G590 Flu shot 4.50 TOTAL for 1 house call (2 patients) $168.50 The next step ... Think of one patient in your practice who would benefit from a home visit In a pairs or groups of 3, describe that patient, why you think they would benefit from a home visit In the next 2-3 weeks, do a house call. Report back to your partner or group (email ... no patient names though). Please cc me too - caroline.knight@rogers.com. Reflection on the house call experience What did you learn about the patient that you didn’t already know? What changes did you make to your management? How did the patient and family react to you making a house call? What went well? What would you do differently next time? Questions? Photo courtesy of Dr Alice Gwyn, Nfld References N Stall, M Nowaczynski, S Sinha. Back to the future: home based primary care for older homebound Canadians. Canadian Family Physician (50) 237-240 March 2013 http://www.cfp.ca/content/59/3/237/T1.expansion.html The Past, Present and Future of Housecalls. Kao et al. Clin Geriatr Med 25(2009)19 -34 BK Unwin, PE Tatum, Am Fam Physician/ 2-11;83(8):925-31. Excellent summary with checklist (INHOMESSS mnemonic), list of equipment References House Call Safety http://osach.ca/products/resrcdoc/lap_301.pdf http://giic.rgps.on.ca/files/Be%20Safe%20Guide%20to%20Home%20 Visits%20from%20Providence%20Healthcare.pdf Bed Bugs References Getting Paid OHIP Schedule of Benefits October 1 2013 OHIP Infobulletin #11064 February 25, 2013 SFGP Common Family Practice Codes - January 1 2013 OMA Primary Care Comparison - March 2013 https://www.oma.org/Member/Resources/Documents/PCRCo mparisonChart.pdf National Physicians Survey 2007, 2010