VA takes team approach to in-home primary care
Part 2 of a two-part series
Recent research shows that a Veterans Affairs’ (VA) program providing home-based primary care has resulted in patients reporting a higher health-related quality of life and greater satisfaction with their care than the typical home care program.
The VA’s home health program is multidisciplinary with a physician leader, nurses, therapists, a social worker, often a dietitian, and even some other disciplines, such as a pharmacist or clergy, depending on the particular VA program’s size, budget, and needs, says Frances Weaver, PhD, deputy director of the health services research and development center at Hines (IL) VA Hos-pital, and a research associate professor at the Institute for Health Services and Policy Research at Northwestern University in Evanston, IL.
In all, more than 70, or one-third of all VA hospitals, have a home-based primary care program, and these programs have existed since the 1970s, Weaver says.
Weaver was one of the investigators involved with studying the program’s outcomes, publishing the results in the Dec. 13 issue of the Journal of the American Medical Association. The study was funded by the VA Health Services Research and Development Program and the VA Cooperative Studies Program.
It works, but it costs more
The study found that patients and caregivers receiving the team-managed home-based primary care approach, when compared with patients receiving the typical and customary care, were more satisfied with their care, caregiver burden was lower, and health-related quality of life was better. The primary care approach also resulted in fewer hospital readmissions in the short term, although this difference dissipated over a 12-month period, and did not save money because the primary-based home care was more costly than the typical home care treatment.
"The reason we got involved in the study was because there was a physician here at Hines who was the medical director of the home care program; she thought it was a unique program, and [thought] we ought to evaluate it to take a look at its cost and whether it was worth the investment," Weaver explains. "We also wanted to see what impact the program had on patients and informal caregivers."
That particular study actually took place in the late 1980s. It found upon evaluation of a single site that there was a cost savings and increased patient and caregiver satisfaction. Based on that small study, the VA agreed to fund a multisite study, which began in the 1990s and involved 16 programs across the country, Weaver says.
The study, which was conducted from October 1994 to September 1998, involved 1,966 patients with a mean age of 70 years. The patients in the home-based primary care group and in the control group were greater than 96% male and had very similar demographics with regards to race, income, education, marital status, and living arrangements. The patients had two or more activities of daily living impairments or a terminal illness, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD).1
Researchers measured patients’ functional status, patient and caregiver health-related quality of life and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months.1 (See story on study’s findings, p. 47.)
"We monitored all health care costs for both VA and non-VA care over 12 months; and at the end of the study, we found that those individuals followed by the VA home care program had costs averaging 12% more on average than the usual customary care group," Weaver says.
Here’s how the VA program typically works:
1. Provide active physician involvement.
Physicians make home visits and participate in team meetings to discuss patients and their status, Weaver says.
The study showed that on average patients received 0.8 physician visits to their home. "A significant number did have a physician visit, and I believe that plays into their higher satisfaction rate," Weaver says.
Physicians monitor patients’ use of VA inpatient hospital care and keep in close communication with hospital personnel.
2. Offer multidisciplinary care.
Besides having a physician on the primary care team, most of the VA home-based primary care programs also have a RN or MSN nurse, a social worker, and a dietitian. Some of the programs provide services from LPNs, nurse practitioners, pharmacy, physical therapy, occupational therapy or kinesiotherapist, health tech, or even a laboratory technician, although personal aide services are not provided.2
Patients particularly like the interdisciplinary nature of the program, Weaver says.
"The VA program has more flexibility than customary home care, and it can change care plans," she explains. "If a patient is having a nutritional problem or a psychological problem, then we can have a nutritionist or psychologist go out to the home."
Two more advantages the VA program has over traditional home health is that it is not constrained to restorative or post-acute care, and there are no limits placed on the number of visits staff might make to see a patient. The VA programs are funded out of the hospital budgets so home care visits are assessed according to the value of the visit, vs. admitting a patient to the hospital for care.2
3. Offer patients after-hours assistance.
The VA study found that patients of the VA home-based primary care program were more likely than customary home health patients to know whom they should call if they had an emergency, Weaver notes. "The patients in the VA program identified the VA’s home care program as the place to call, while the customary care folks were less certain about who to call."
And when the VA patients did call the home-based primary care program, they were more satisfied than the control group with the telephone interaction and were less likely to end up going to the emergency room because the VA team could provide them with triage over the telephone, Weaver adds.
4. Train nurses to work toward the most important goals.
The patients selected for the study were extremely ill. About 20% were terminally ill, and about 75% of those who were not terminally ill were severely disabled. Small percentages of the patients who were not terminally ill had CHF or COPD.
The home-based primary care team nurses were trained to attend to the most important goals of those patients.
For example, the VA nurses work with caregivers to help prevent patients from having exacerbations that could lead to hospitalization. This is particularly true in the cases of CHF and COPD patients, who are among the highest users of health care services because of their frequent symptom flare-ups and the chronic nature of their diseases.
"Seventy percent of them — within a year — had one or more readmissions," Weaver says. "Those particular populations are very difficult to manage because of acute exacerbations."
The nurses also focus on teaching patients and caregivers how patients can maintain their weight, follow dietary plans, reduce salt intake, and identify symptoms and problems before they become serious enough to require hospitalization, Weaver says.
Members of the VA’s home-based primary care team typically had a smaller caseload than the customary home health providers.
References
1. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based Primary care: A randomized multicenter trial. JAMA 2000; 284:2,877-2,885.
2. Weaver FM, Hughes SL, Kubal JD, et al. A profile of Department of Veterans Affairs hospital-based home care programs. Home Health Care Serv Q 1995; 15:83-96. n
• Frances Weaver, PhD, Deputy Director of Health Services Research and Development Center, and Research Associate Professor, Institute for Health Services and Policy Research, Northwestern University, Evanston, IL, and Hines VA Hospital, HSR&D 151H, Hines, IL 60141. Phone: (708) 202-8387.
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