How IAH House Call Model Works

K. Eric De Jonge, M.D.

Washington Hospital Center

Washington D.C.

Campaign for Better Care Webinar

June 30, 2010

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,

• 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?”

• 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 PrimaryCare

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