2015-307 - Texas Occupational Therapy Association

Integration of Occupational Therapy to the HomeBased Primary (HBPC) Program for Veterans
Texas Occupational Therapy Conference Mountain
Central Conference
Presented by:
Dr. Katherine Lawson, OTR, LMSSW, Ph.D.,
Civil War era soldier’s hospital Photo by Matthew Brady By Hans Petersen Monday, March 2, 2015
VA was elevated to a Cabinet-level executive department by President Ronald
Reagan on October 15, 1988
President Reagan Elevates VA to Cabinet Level Photo by Michael Moore
The National Center for Veterans Analysis and Statistics (NCVAS)
VA Health Care Started 150 Years Ago
Congress established new benefits for World War I Veterans as U.S. enters
World War I in 1917
Life insurance
Disability compensation
Vocational rehabilitation
New federal agencies to administer these benefits
Federal Veterans medical care shifted from lifelong residential care to shortterm treatment in general or specialized hospitals, supplemented by job retraining or disability pensions.
August 1945 - General Omar Bradley takes the reins at VA and steers its
transformation into a modern organization
January 1946 - Public Law 293 establishes VA’s Department of Medicine and
Surgery, along with numerous other programs like the VA Voluntary Service
to provide better services to Veterans. The law enabled establishment of
medical services to be on par with the private sector.
The National Center for Veterans Analysis and
Statistics (NCVAS) as of 9/30/2013
The National Center for Veterans Analysis and
Statistics (NCVAS) as of 9/30/2013
The National Center for Veterans Analysis and
Statistics (NCVAS) as of 12/31/2013
To provide comprehensive long
term health care that is easily
accessible and well coordinated
for Veterans with complex
chronic diseases living within
the community.
El Paso, Texas VA Health Care System’s
(ELPVAHCS)Home Based Primary Care, (HBPC)
The El Paso Home Based Primary Care (HBPC) program
began in August of 2011. The program provides a
comprehensive case management to veterans who require
the majority of their primary health care needs
accomplished in the home.
The HBPC program is operated by the VA office of
Geriatrics and Extended Care, and serves veterans with
disabling chronic conditions for whom periodic doctor visits
are insufficient.
Veterans are selected for the program based on clinical
diagnoses, the risk of repeat hospitalizations and nursing
home stays and proximity to a VA facility where a HBPC
team is based. (To cover the rural area we have the Las
Cruces, New Mexico Home Based Primary Care).
Veterans are referred by their primary VA care physician.
To create a safe and trusting
atmosphere in the home where
Veterans can feel comfortable in
learning how to manage their own
health care needs to the best of their
ability thus reducing the need for
repeated hospitalization, emergency
room visits or unscheduled clinic visits.
Guiding Principle
To offer our Veterans consistent
support, health care guidance, and
education while striving to achieve and
maintain health. HBPC values and
respects each veteran and the sacrifices
made for our freedom. It is our hope to
provide the highest quality of care and
customer satisfaction to our Veterans
and families at all times.
Medical Director of
Home Based Primary
Care Program
Director of Home Based
Primary Care Program
Nurse Practitioner
Nurse Practitioner
RNs (3)
Case Managers
RNs (3)
Case Managers
HBPC Core Team
Registered Nurses-6
Occupational Therapist-1
Social Workers-2
Nurse Practitioners-2
The HBPC team closely communicates with each
other to offer consistent, holistic, and complete
health care management
HBPC Interdisciplinary Treatment Team
Primary Care Provider (PCP)-The PCP is the Nurse
Practitioner under the supervision of The Director of
Primary Home Based Program. The Nurse Practitioner
coordinates the Veterans health care related needs and
services to best achieve and maintain their health.
RN Case Manager-Coordinates health care needs with the
Nurse Practitioner and other Core Interdisciplinary
Members. During routine home visits the RN will complete
a comprehensive physical assessment, provide treatments
such as catheter management, medication box set up,
venipuncture, wound care, and other health care services
requested by the PCP.
Psychologist-The home care psychologist is
available to help the Veteran and caregiver learn to
cope with psychological and physical stressors that
HBPC Interdisciplinary Treatment Team, cont.
often develop
from living with a chronic mental
and/or physical disease. The psychologist can help
the Veteran explore why they may be experiencing
feelings such as helplessness, depression,
irritability/frustration, and anger. The psychologist is
available to offer support and guidance for patients
who may be experiencing military & non-military
trauma related to grief and loss.
Pharmacist-The pharmacist collaborates with the
PCP and other members of the home care team to
ensure that the Veteran is receiving the most
appropriate medications for their conditions. The
pharmacist regularly reviews the Veterans
medications for drug interactions, side effects,
efficacy, and appropriateness of therapy.
HBPC Social Worker-Assist the Veteran and his/her family with social,
financial, and emotional support needs. The social worker assist in obtaining
additional community resources, VA benefits or other supportive needs as
assessed required maximizing the Veterans care needs. The social worker
also assist with developing and answering any questions about Advance
Directives and or End of Life wishes.
Medical Foster Home Social Worker-assist the Veteran in placement into a
private foster home inspected by and approved by all members of the HBPC
team, VA inspector and City inspector. The Veteran is responsible for the
costs of residing in a VA medical foster home. Costs is based on level of care
and financial resources. While each member of the HBPC team. No more
than three patients are allowed to be in a VA certified medical foster home.
Dietitian-Assist the Veteran with nutritional needs. He or she helps the
Veteran plan meals and grocery-shopping making it easier to follow the
nutritional recommendations the PCP has prescribed. The home care
dietitian educates the Veteran on required nutritional guidelines for
controlling diabetes and heart disease. Tin the medical foster home, the
Veteran continues to receive services from he dietitian also teaches the
Veteran possible interactions from medications and over the counter
vitamins, minerals, and plant supplements he/she may be taking.
Occupational Therapist, (OTR)-Assist the Veteran
with safety and functional independence within the
home. The OTR assesses level of independence with
activities of daily living such as dressing, bathing,
and preparing meals, self-care and mobility
in/around the home and will make
recommendations for home modifications that will
increase his/her safety and independence. The
home environment will be assessed for
recommendations for structural modifications
needed to make the home environment safe and
accessible as well as determining what home
medical equipment may be needed to enhance the
Veterans ability to be safe and care for
Current Enrollment: 125
Average: 12,000 Veterans
El Paso
HBPC Veteran
5% Females & 95% Males
4% Females & 96% Males
Heart Disease: 54%
Heart Disease: 72%
Dementia: 17%
Dementia: 33%
Diabetes: 52%
Diabetes: 48%
Cancer: 29%
Cancer: 29%
Depression: 32%
Depression: 44%
Substance Abuse: 11%
Substance Abuse: 29%
Schizophrenia: 6%
Schizophrenia: 20%
Average Age: 74.1
(<65=26%, >65=79%)
Age Range: 30-97
Average Age: 76.5
Veteran Characteristics, cont.
National Average: Co-Morbidities = 5, (CDC., 2015)
HBPC Program: Co-Morbidities
Veteran Characteristics
Pain: 79% (<65=14%) (>65=65%)
Heart Disease: 54% (<65=3%) (>65=51%)
CVA: 27% (<65=3%) (>65=20%)
Dementia: 54% (<65=4%) (>65=50%)
HTN: 79% (<65=21%) (>65=58%)
Diabetes: 71% (<65=12%) (>65=59%)
COPD: 15% (<65=3%) (>65=12%)
Cancer: 29% (<65=8%) (>65=21%)
Falls: 23% (<65=7%) (>65=16%)
Depression: 32% (<65=6%) (>65=26%)
Parkinson’s: 9%, (<65=0)
Schizophrenia: 20% (<65=12%) (>65=8%)
Arthritis: 65%, (<65=9%)
Legally Blind: 13%, (<65=3%) (>65=10%)
Alzheimer’s: 2%, (>65=2%)
Substance Abuse: 29% (<65=3%)
Readmission rates
(agencies reporting greater than 40% readmissions)
All agencies
Facility based
For profit
Government (VA)
Rural, adjacent to urban
Rural, nonadjacent to urban
States with the highest readmission rate (74%) = LA, MS, OK, TX
All other States = 55%
Note: A Micropolitan county has a population of 10,000 to 50,000. Source: Based on Med PAC analysis of University of Colorado data. Med Pac
Comparison of agencies with the highest readmission rates
(Top quartile) with other agencies:
All other
Top quartile
of readmission rates
Readmission rate
Average number of admissions
Agency length of stay
Share of agencies:
In 4 states with highest rates
of readmission (LA, MS, OK, TX)
For profit
Facility based
Source: Med PAC analysis of University of Colorado data on readmissions to hospitals from home health (2014)
Readmission Rates
January-9 (Resp. Distress,
Hypotensive Episode, UTI, Altered
Mental State, CVA, Atrial Fib, Fluid
Overload, Fall, and UTI. 7.2%
February-11 (UTI, Psychiatric episode,
Fall, Lung Cancer, UTI (Pneumonia,
Fluid in lungs), Wound, Fluid
Retention, Foot fracture, SOB, ESRD,
and SOB. 8.8%
March-9 (Pneu., Respiratory Distress, April-6 (Viral Infection, COPD, Fluid
Pneu., CVA, Suicide Attempt, SOB,
Buildup, Respiratory Failure, Urine
Pnue, Disorientation, and
Backup, and CVA. 4.8%
SOB/Vomiting. 7.2%
May-6 (Chest Pain, Heart Failure,
Liver Failure, Kidney Failure,
Pyelonephritis, and GI Bleed. 4.8%
June-7 (Fecal Impaction, Syncopal
episode, DVT, Appendicitis, ESRD,
Facial Surgery (secondary to cancer),
and cellulitis. 5.6%
July-5 (SOB, COPD, UTI,
August-6 (DVT, Amputated Foot,
Osteomyelitis, Pnue, and Respiratory COPD, DVT and Fall, Ankle Fracture,
Distress. 4%
and Pneu. 4.8%
Pros of HBPC Model
Keeping the veteran connected to Medical Services and
Community Resources in order to allow for productive
aging within his/her home setting.
Access to a Multidisciplinary Medical Team: dietitian,
medical director, nurse practitioners, nurses, occupational
therapist, psychologist, social workers, and pharmacist.
Veterans are seen monthly by the case manager and
annually by other disciplines (unless more visits are
Rank third nationally for preventing re-admissions.
Transportation is not an issue since Veterans are seen at
Veterans are offered daycare, aide and attendance
services, and respite care.
Veterans are offered Medical Foster Home Placement if
functional level and amount of care changes.
Preventing Crimes Against the Elderly
•Self-Abuse/ Neglect
•Financial Exploitation
•Family Members
•Scam Artists
Limitations of HBPC Program
Tracking of Home Health Care paid for by the VA vs.
Medicare paid Home Care.
Medication-outside providers and overprescribing of
DME-ordering of unnecessary DME.
Difficulty with Veterans understanding each HBPC
disciplines role and that they are under the care of a Nurse
Practitioner versus going to the VA to see a Primary Care
Physician. This has to do with educating the Veteran about
the program on an ongoing bases. The Veteran is used to
seeing multi-disciplines in different departments versus
each discipline coming to his/her home.
Outsourcing of certain services (cardiac, pulmonary,
nephrology, oncology, etc.).
A "Noble Dream" to Honor Our Patriots
The noble dream of providing care for the nation's patriots began as a
simple idea to fill a need in the midst of war in 1863. Our nation's
leaders legally authorized it on March 3, 1865. There was no model to
follow; this kind of Veterans care didn't exist in the world. What they
created was unprecedented.
Today's VHA —is the largest program within the VA. We continue to
meet Veterans' changing medical, surgical, and quality-of-life needs.
Our programs provide treatment for traumatic brain injuries, posttraumatic stress, suicide prevention, and programs specific to Women
Veterans. The VA has outpatient clinics, and established telemedicine
and other services to accommodate a diverse Veteran population. The
goal is to cultivate ongoing medical research and innovation to
improve the lives of America's patriots.
The VA health care system has grown from 54 hospitals in 1930. We
currently have 150 hospitals, 800 community-based outpatient clinics,
126 nursing home care units , and 35 domiciliaries.
• Centers for Disease Control. Accessed October 2015.
• Edes, T., Kinosian, B., Vuckovic, N.H., Nichols, L.O., Becker, M.M., &
Hossain, M.S. 2014. Better Access, Quality, and Cost for Clinically
Complex Veterans with Home-Based Primary Care. Journal American
Geriatric Society. 62: 1054-1961.
• Edwards, T.S., Prentice, J.C., Simon, S.R., & Pizer, S.D. 2014. HomeBased Primary Care and the Risk of Ambulatory Care-Sensitive
Condition Among Older Veterans With Diabetes Mellitus. JAMA
Internal Medicine. Doi: 10:1001. E1-E8.
• Stall, N., Nowacyzncki, M., & Sinha, S.K. 2014. Systematic Review of
Outcomes from Home-Based Primary Care Programs for Homebound
Older Adults. Journal American Geriatrics Society. Doi: 10.1111. 1-9.
• The National Center for Veterans Analysis and Statistics (NCVAS).
Accessed 5-4-15.