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 Prosthetics Vocational rehabilitation Hospitalization 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 Mission 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. Vision 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 Pharmacist Psychologist RNs (3) Case Managers OTR MSW Dietician HBPC Core Team Registered Nurses-6 Dietician-1 Psychologist-1 Pharmacist-1 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 himself/herself. Current Enrollment: 125 Veterans National Average: 12,000 Veterans El Paso HBPC Veteran Characteristics 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 2-9=3%, 10-19=29%, 20-29=35%, 30-39=21%, 40-49=7% 50-59=5% Veteran Characteristics Diagnoses 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) (>65=9%) Schizophrenia: 20% (<65=12%) (>65=8%) Arthritis: 65%, (<65=9%) (>65=56%) Legally Blind: 13%, (<65=3%) (>65=10%) Alzheimer’s: 2%, (>65=2%) Substance Abuse: 29% (<65=3%) (>65=26%) Readmission rates (agencies reporting greater than 40% readmissions) Percent All agencies 60% Freestanding 61% Facility based 46% For profit 65% Government (VA) 48% Nonprofit 44% Urban 60% Metropolitan 57% Rural, adjacent to urban 58% Rural, nonadjacent to urban 59% 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 (2014) 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 58 26 347 46.0 97 64.2 Share of agencies: In 4 states with highest rates 19% of readmission (LA, MS, OK, TX) 45% For profit Facility based Rural 90% 4% 16% 69% 15% 22% 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 needed). Rank third nationally for preventing re-admissions. Transportation is not an issue since Veterans are seen at home. 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 •Falls •Self-Abuse/ Neglect •Financial Exploitation •Age •Disability •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 medications. 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. Questions? References • 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.