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.