Improving outcomes and lowering costs by applying advanced models of in-home care

PACE: SYSTEM-BASED HOME CARE

In the 1980s, health maintenance organization risk contracts seemed a likely context for developing advanced home care models, but this did not happen. However, the Program for All-Inclusive Care of the Elderly (PACE) was tested and became a defined federal benefit in 1997. There are now nearly 100 PACE centers nationwide. PACE offers comprehensive care for people aged 55 years and older who are nursing home–eligible. The program appears to effectively help people stay home.²³

An interdisciplinary team (IDT) coordinates PACE medical and social services to promote independence and quality of life. The program has been referred to as “a nursing home without walls.” Services include primary and specialty care, adult day care, case management, nursing, home health care, assistance with activities of daily living (ADL), medications, social work, rehabilitation, hospitalization, nursing facility care, nutritional support, caregiver respite, and transportation to and from the PACE adult day health center (ADHC) and medical appointments. The ADHC is the cornerstone and coordinating center for most care provided to PACE participants. Home-based care is provided in several ways:

• Home nursing care may be provided by external agencies, including skilled care, personal care, and hospice care, under contract with PACE. In Richmond, the home care manager oversees care after it is approved by the IDT. Weekly hours of care are changed often according to the participant’s need (eg, increased hours after hospital discharge and decreased hours when a family member visits and can provide more care). Home care provides assistance with ADLs and instrumental ADLs; “sitter” services are provided at the ADHC.
• The program supports home modifications and provides durable medical equipment (DME). Assessment is done by one or more team members upon enrollment and then at least every 6 months. PACE provides all DME the participant needs to remain safely in the community. At disenrollment or death, some equipment can be returned to PACE after review by the rehabilitation department.
• Primary care, basic laboratory services, and medical specialty care can be provided to the participant at home if for any reason he or she is unable to travel to the ADHC. PACE physicians make house calls to better understand patients’ living situations and needs. On-call nurses make home visits after hours or on weekends for clinical assessments, point-of-care diagnostic testing, specimen collection (stool or urine), and participant and family education on proper use of medications or equipment.
• As PACE participants approach the end of life, they transition to a palliative care model. A decision is made by the family and the IDT to discontinue attendance at the ADHC and to focus on care at home,²⁴ allowing the participant to spend the last days or weeks in the relative comfort of home. Nurses make home visits when needed and educate families on symptom palliation.
• Additional in-home respite services can be provided to decrease caregiver burden.
• Skilled rehabilitation services are delivered either at home or in the ADHC depending on the judgment of the rehabilitation department and the IDT. The PACE site offers advanced transportation and full onsite therapy services 5 days per week.

The PACE sites become the insurers, receive defined capitation payments from Medicare and Medicaid that are adjusted for patient complexity, and assume the risk for all health care costs. Because of a 5% withholding in the capitation amount relative to projected Medicare expenses, PACE should reduce governmental costs. PACE must provide or pay for all usual Medicare and Medicaid services, and it may provide other services deemed necessary by the PACE team. Within PACE, hospital use is markedly reduced compared with conventional Medicare,²⁵ and home care is one of several strategies employed. The PACE experience shows that care can be safely shifted from hospitals to other settings.

IMPACT ON MEDICAL EDUCATION

Since 1984, several thousand medical students; internal medicine residents; geriatric fellows; and N P, social work, and pharmacy students have participated in the VCU House Calls program and have come to see home care as a viable care model. House calls have been mandatory in the VCU School of Medicine curriculum since 2002. Qualitative evidence from these encounters demonstrates that learners value the experience and gain a better understanding of health care as a result.

Medical students’ interest in geriatrics is low,^26,27 but positive, intense, or unique experiences with elders, and interactions with positive role models may improve the outlook for the specialty. The home setting gives learners an opportunity to observe the care of medically complex patients in the community, exposes the students to the team of professionals needed for comprehensive care, and enhances learners’ awareness of the challenges in providing continuity of care for this population.

We previously reported on a qualitative study of comments of second-year medical students who participated in our House Calls program.²⁸ Students frequently noted the apparent comfort and positive attitude of the patients; the dedication, patience, compassion, commitment, and hard work of the caregivers; and the personalized and comprehensive care provided. The students identified both the challenges and the rewards for the doctors and expressed increased interest in conducting house calls in the future.

The training of competent and caring physicians and other health professionals is the goal of medical education. Fourth-year medical students were surveyed nationally regarding the qualities of a humanistic doctor.²⁹ The students noted the importance of role models and participatory experiences. House calls provide an opportunity for learners to see health care in the community. Such experiences can create a memorable lesson in care delivery and in doctor-patient-caregiver relationships.

PALLIATIVE CARE AND HOME CARE

Ideally, care plans would gradually shift in focus from curative therapy to palliative care as patients with significant chronic illness advance in age and debility. In our geriatric practice, palliation is always important throughout extended chronic illness. Care plans progress and palliation becomes the primary focus in the final months of life. This transition may take years. Hospice referral is frequently a final step because the payment system reimburses for comprehensive team-based hospice care only when life expectancy is less than 6 months. The reason for this is economic: comprehensive team-based care is costly, and lengthening the hospice benefit as it is now structured could be prohibitively expensive. Our patients may live for years in a state of advanced debility, yet need intensive team care only at intervals. Optimally, the care model, team intensity, and related payments should flex with clinical need. This is what we have experienced by making house calls the mode of longitudinal primary care delivery, supported by our institution. Our teams help patients and families shift focus and decide when to accept hospice care; this requires more art than science and usually involves a gradual process of adaptation.

Our approach is consistent with the definition of palliative care published by the Centers for Medicare & Medicaid Services in 2008: patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs and facilitates patient autonomy, access to information, and choice.³⁰ Geriatric clinicians seek to help patients and families maximize quality of life and to maintain function by focusing on symptom management and clarification of patient and family goals rather than on specific diseases. This approach is applied without regard to patient age, condition, or stage of disease, and it can coexist with curative treatments. Thus it is distinguished in concept from “what we do when there is nothing more we can do.”³¹

In ways that are less clear when working in other care settings, home visits reveal patient goals, true rehabilitative potential, and family capacity for care-giving. Home visits take longer than office encounters, but make the provider’s job easier. By observing the patient at home, providers can better assess barriers to comfort and devise strategies to improve function, while also evaluating whether life is truly nearing the end. The home care clinician often engages in palliative care even if he or she did not initially intend to do so.

Furthermore, compared with the hospital or office setting, a home is more conducive to reasonably paced discussions about goals of care. Patients are more physically and emotionally comfortable and may talk more easily about potentially disturbing subjects. The clinician may be able to engage the patient by referring to pictures or mementos that help the patient to reflect on life values. And, a patient who is seen at home will more readily trust that the clinician places patients’ needs first. This opens the door to difficult discussions about code status, health care proxies, dialysis and ventilator support, or whether the patient would ever want to go to a hospital or a nursing home. Preferences change with time; patients ultimately feel less need to rely on ambulances and emergency care, given a timely response at home from a clinician who is familiar.³²

Most dying patients are at home with their families during most of their final year of life; yet, despite studies showing that most patients prefer to die at home^33–35 about 60% of all deaths still occur in the hospital.³⁶ In our House Calls program’s experience, the percentage of patients who die at home is closer to 60.

Cherin and colleagues³² described a successful end-of-life home care program demonstrating a significant benefit to patients over usual care. The program integrated curative and palliative therapies. Similarly, Brumley and colleagues³⁷ demonstrated that, compared with usual care, patients receiving in-home palliative care reported greater satisfaction, had fewer emergency department and hospital visits, and were more likely to die at home, with significantly lower overall costs. These findings conform to our experience. (Also see “Innovative models of home-based palliative care”)

CONCLUSION

Advanced home care with a strong medical component is an important part of the supportive and recuperative care options in the United States. For these programs to reach their full potential, we must expand on the successful in-home medical care models and create responsible financing methods that control overall costs while rewarding providers appropriately. We must broaden the application of portable and information technologies and develop an interdisciplinary workforce. These approaches will lead us toward our overall goals of optimal care at minimal cost.