The Outcomes and Reimbursement in
Home Care
1
Joan Escarrabill MDChronic Care Program– Barcelona Esquerra. Hospital Clínic (Barcelona)
Master Plan for Respiratory Diseases (PDMAR) & Home Respiratory Therapies Observatory (ObsTRD). FORES. Ministry of Health (Catalonia)Ankara, November 15th 2013
Agenda
2
Home care
Context
Alternatives
Outcomes
Historically, most health care was provided in the home
3
N Engl J Med 1997;337: 1815-20.
1930 1950 198005
10152025303540
40
10
0.6
% house calls in patient–physician encounters
%
Types of visits in Primary Care
2005 2006 2007 2008 200934,000,000
35,000,000
36,000,000
37,000,000
38,000,000
39,000,000
40,000,000
41,000,000
42,000,000
Primary Care Visits
Visits PC
Phone contact4%
Visit94%
Home care2%
2009
Visit99%
Home care1%
2005
Home care Primary Care ICS (2010)
30%
63%
2%5%
Doctors NursesSocial workers Home care support
Who cares at home?
91%
6%
3%
Office visits Phone calls Home visits
Place of care
Total number of consultations: 33.420.762
Mainly out-of-hours
Mainly long-term care (ATDOM)
6
Home oxygen therapy (1885)
There is no place like home
7
There are clinical reasons to avoid hospitalization
Inactivity
In the hospital
Social isolation
Overmedication
Adverse events
Different services in one place
Out-of-Hours• Nursing care• Out-of-Hours Service
Support from discharge• Hospital at home• Transitional care
Long-term care• “Preventive”• Specialized
Procedures at home• Drug administration
Definition: a difficult task
Aten Primaria 2002;30:304-309
Criteria Definition
Duration of care Short < 15 days or long > 60 days
Complexity Devices, decissions, daily life support
Intensity Number of visitis per day
Speed of response Emergencies / Support from discharge
Coverage 24/7/265 vs working hours
You can set the standards of care based on criteria
Definition: a difficult task
Out-of-Hours
Hospital at home
Transitio-nal care
Long-term (ATDOM)
Long-term(Specialist)
Procedures
Duration of care
Short < 15 days < 60 days > 60 days > 60 days Days
Complexity Very low Low Low Low Very high High
Intensity Once High (twice/day?)
Once a week ?
Low Once a month?
Daily
Speed of response
Same day High Low Scheduled Immediately Quick
Coverage Out of working hours
24/7/365 Working hours
Working hours
24/7/365 24/7/365
From transitional care to long-term care
Acute care
Primary care
Hospital at home
Transitional care
Long-term care
Specialised long-term care
RehabilitationPalliative care
Home mechanical ventilationNutrition (enteral/parenteral)Peritoneal dialysis
From transitional care to long-term care
Primary care
Transitional care
Long-term care
Specialised long-term care
RehabilitationPalliative care
Home mechanical ventilationNutrition (enteral/parenteral)Peritoneal dialysis
It is often difficult to draw the line between transitional care and long-term care
1
It is not easy to define the role of generalist and specialist
2
Evaluation of home care
From
Products
To
Services
Number of visitsPhone callsAdmissions….
Meet the needs of patients according to local resources
Agenda
14
Home care
Context
Alternatives
Outcomes
Home care strategies
15
Home care from Primary care
Post-diascharge & Hospital at home
Long-term & Integrated care
Long-term & HMV
Palliative care
1
2
3
4
5
Home care from primary care services
Aten Primaria 2003;31:473-9
Nursing leadership
Main protocolsPressure ulcersEnd-of-life Bedridden patientsPain
Main problemsLack of timeScarce social resourcesPoor coordination
1
BMJ 2005;329:315-20
2
COPD: Hospital at home
Escarrabill J.Eur Respir J 2009; 34: 507–512
22% refuse
19
Hernández. Eur Resp J 2003;21:58-6.
Home care Convencional p
Mortality (%) 4,1 6,9
Readmisions (%) 20 27,7
Visits ER 0.13 (0.43) 0.31 (0.62) 0.01
LOS hospital (days) 1.71 (2.33) 4.15 (4.1) < 0.001
% admissions > 3 days 16.5 47.5 < 0.001
LOS home (days) 3,56 (1-14)
Home visits 1.56 (1.31)
Phone calls 2.33 (2-05)
Satisfaction 8.0 7.5 0.03
Age: 70.8 9.8 yearsFEV1 1.1 0.5 l.
Hernández C. Eur Resp J 2003;21:58-6
Intervention effectsConventional tharapy Home care
Cost = 38% lower in home care
21
Eur Respir J 2006;28:123-30
Función respiratoria Co-morbilidadProblemas sociales
Deshabituación tabáquica
Conocimiento de la enfermedad
Tratamiento inhalatorio
Actividad física
Signos y síntomas de alarma
Educación (auto-cuidado)
Programa de asistencia
personalizda
Coodinación entre los diversos dispositivos asistenciales
Valoración global
3
Integrated care
Long-term follow up by specialists in LTOT
Chest 2001; 119:364–369
ER visits Admissions LOS02468
101214161820
Chnages related to home care
Home care Control
Positive inpact of nurse/respiratory therapist +
telephone + home visit
Chest 2005; 127:2132–2138
Protocol
Benefits of “package of care”: assessment + follow up +
home support
4
Eur Respir J 2010; 35: 310–316
5,4 Calls/patient/year
6% Requiered home care
25/188 no mechanical fault was identified
13 patients were either found to be unwell or required hospital admission
25
Systemaic follow-up
Escarrabill J. Breathe 2009;6:37-42.
Population: 291.500.000
26Escarrabill J. Breathe 2009;6:37-42.
Grups petits de pacients. Seguiment curt Variabilitat terminológica Diferents intervencions Orientats a malalties – poc holístic
27
PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238
No queda clar si els efectes es relacionan amb la telemonitorització (e-Health) o amb el canvi d’estratègia assistencial
28
PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238
“Digital Health Divide”
Hi ha grups de pacients que no estan prou representats en els estudis:
Multimobilitat Trastorns cognitius Problemes socials Discapacitats
29
Pinnok et al. BMJ 2013;347:f6070 doi: 10.1136/bmj.f6070
Risc d’ingrés
Journal of Telemedicine and Telecare 2012; 18: 211–220
Home care support teams
Gómez-Batiste X et al. J Pain Symptom Manage 2010;40:652-60
5
32
Gómez-Batiste X et al. J Pain Symptom Manage 2006;31:522-32
34%
14%14%
26%
9%3%
Home visits Hospital admission GP Visit Phone call Outpatient clinic Others
Health Care Interventions
n=395
Agenda
33
Home care
Context
Alternatives
Outcomes
34
Value =Outcomes
Cost
NEJM 2010;363:2477-81
NEJM 2010;363:2477-81
The Outcome Measures Hierarchy.
• Time to recovery.
• Desutilities
• Sustainability of health
• Long-term consequences
Focus on results
Some mistakes can be made speaking of results
1 Believe that the results of the pilot studies can be extrapolated automatically
3 Average approach is harmful
2 The results must to be good in the full process
4 The time, from the point of view of patients, is not process is a key result.
Home care evaluation
Health System
Specific program
Patient
37
Patient experienceHealth results
CoverageSpecific objectives
SustainabilityPopulation Impact
38
NEJM 2013;368:201-3
Patient experience (i)
39
Time• Waiting• Response• Resolution
Resolution capability
• How many professionals are involved to solve the problems?
Co-participation• Several options• Decission-making process• Deliberation
Information• Intelligible• At the right time
Patient experience (ii)
40
Utility • How much was useful…
Interference• Inconveniences that generated the
activity in their daily lives
Benefit• Will the benefits outweigh the
drawbacks?
Maintenance• To what extent it will be possible to
maintain ....?
Indicators
• Intra-hosp• Resolution • Hospital
days/yerar
• Age/gender• Diagnostic• Comorbidity
• Admission• Readmission• Visits
Transitions and
contacts
Demography
Mortality
Care cycle
41
42
BMJ 2012;345:e6017
43
BMJ 2012;345:e6017
The paradox of "pilot studies"
Pilot studies Real life
Good results
Good
acceptance
Scientific
reconnaisance
No impact
Eur J Cardiovasc Nurs. 2011 Mar 12.
43%
32%
“Value-based purchasing”
The value is measured by considering the "whole process"
not every "individual procedures"
Març 2009
… and health professionals (mainly physicians) they prefer the arts to science
Standardization
48 JAMA 2013;309:355-363
Ann Intern Med. 2010;153:167-175.