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Home care
- 1. The Outcomes and Reimbursement in Home Care Joan Escarrabill MD Chronic Care Program– Barcelona Esquerra. Hospital Clínic (Barcelona) Ankara, November 15th 2013 1 Master Plan for Respiratory Diseases (PDMAR) & Home Respiratory Therapies Observatory (ObsTRD). FORES. Ministry of Health (Catalonia)
- 3. Historically, most health care was provided in the home N Engl J Med 1997;337: 1815-20. % house calls in patient–physician encounters 40 40 30 10 20 % 0.6 10 0 3 1930 1950 1980
- 4. Types of visits in Primary Care Home care 1% 2005 Phone contact 0% Primary Care Visits 42,000,000 41,000,000 Visit 99% 40,000,000 39,000,000 38,000,000 37,000,000 Home care 2% 36,000,000 2009 35,000,000 34,000,000 2005 2006 2007 2008 2009 Visits PC Visit 94% Phone contact 4%
- 5. Home care Primary Care ICS (2010) Who cares at home? Place of care 6% 3% 2% 5% 30% Mainly outof-hours 63% 91% Mainly long-term care (ATDOM) Doctors Nurses Social workers Home care support Office visits Phone calls Total number of consultations: 33.420.762 Home visits
- 6. Home oxygen therapy (1885) 6
- 7. There is no place like home There are clinical reasons to avoid hospitalization Overmedication Social isolation Adverse events In the hospital Inactivity 7
- 8. 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
- 9. Definition: a difficult task Aten Primaria 2002;30:304-309 You can set the standards of care based on criteria 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
- 10. Definition: a difficult task Out-ofHours Hospital at home Transitional 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 Low Once a month? Daily (twice/day?) Once a week ? 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
- 11. From transitional care to long-term care Primary care Acute care Hospital at home Long-term care Transitional care Rehabilitation Palliative care Specialised long-term care Home mechanical ventilation Nutrition (enteral/parenteral) Peritoneal dialysis
- 12. From transitional care to long-term care 1 It is often difficult to draw the line between transitional care and long-term care Primary care Long-term care Transitional care 2 Rehabilitation Palliative care Specialised long-term care It is not easy to define the role of generalist and specialist Home mechanical ventilation Nutrition (enteral/parenteral) Peritoneal dialysis
- 13. Evaluation of home care From Products To Number of visits Phone calls Admissions …. Services Meet the needs of patients according to local resources
- 15. Home care strategies 1 Home care from Primary care Post-diascharge & Hospital at home 2 3 4 Long-term & Integrated care Long-term & HMV 5 15 Palliative care
- 16. 1 Home care from primary care services Aten Primaria 2003;31:473-9 Main protocols Pressure ulcers End-of-life Bedridden patients Pain Main problems Lack of time Scarce social resources Poor coordination Nursing leadership
- 18. COPD: Hospital at home 22% refuse Escarrabill J. Eur Respir J 2009; 34: 507–512
- 19. Hernández. Eur Resp J 2003;21:58-6. Age: 70.8 9.8 years FEV1 1.1 0.5 l. Home care Convencional 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 16.5 47.5 < 0.001 7.5 0.03 % admissions > 3 days LOS home (days) 1.56 (1.31) Phone calls 2.33 (2-05) Satisfaction 19 3,56 (1-14) Home visits 8.0 p
- 20. Intervention effects Conventional tharapy Home care Cost = 38% lower in home care Hernández C. Eur Resp J 2003;21:58-6
- 21. 3 Eur Respir J 2006;28:123-30 Función respiratoria Co-morbilidad Problemas sociales Valoración global Integrated care Educación (autocuidado) Deshabituación tabáquica Conocimiento de la enfermedad Tratamiento inhalatorio Actividad física Signos y síntomas de alarma 21 Programa de asistencia personalizda Coodinación entre los diversos dispositivos asistenciales
- 22. Long-term follow up by specialists in LTOT Chnages related to home care 20 15 Chest 2001; 119:364–369 10 5 0 ER visits Admissions Home care Positive inpact of nurse/respiratory therapist + telephone + home visit LOS Control
- 23. 4 Chest 2005; 127:2132–2138 Benefits of “package of care”: assessment + follow up + home support Protocol
- 24. 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 Population: 291.500.000 25 Escarrabill J. Breathe 2009;6:37-42.
- 26. 26 Escarrabill J. Breathe 2009;6:37-42.
- 27. PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238 Grups petits de pacients. Seguiment curt Variabilitat terminológica Diferents intervencions Orientats a malalties – poc holístic 27 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: 28 Multimobilitat Trastorns cognitius Problemes socials Discapacitats
- 29. Pinnok et al. BMJ 2013;347:f6070 doi: 10.1136/bmj.f6070 Risc d’ingrés 29
- 30. Journal of Telemedicine and Telecare 2012; 18: 211–220
- 31. 5 Gómez-Batiste X et al. J Pain Symptom Manage 2010;40:652-60 Home care support teams
- 32. Gómez-Batiste X et al. J Pain Symptom Manage 2006;31:522-32 Health Care Interventions 3% 9% 34% 26% 14% n=395 32 Home visits Hospital admission GP Visit 14% Phone call Outpatient clinic Others
- 35. The Outcome Measures Hierarchy. NEJM 2010;363:2477-81 • Time to recovery. • Desutilities • Sustainability of health • Long-term consequences
- 36. Focus on results Some mistakes can be made speaking of results 1 Believe that the results of the pilot studies can be extrapolated automatically 2 The results must to be good in the full process 3 Average approach is harmful 4 The time, from the point of view of patients, is not process is a key result.
- 37. Home care evaluation Health System Sustainability Population Impact Specific program Coverage Specific objectives Patient Patient experience Health results 37
- 39. Patient experience (i) Time Resolution capability Co-participation Information 39 • Waiting • Response • Resolution • How many professionals are involved to solve the problems? • Several options • Decission-making process • Deliberation • Intelligible • At the right time
- 40. Patient experience (ii) Utility Interference Benefit Maintenance 40 • How much was useful… • Inconveniences that generated the activity in their daily lives • Will the benefits outweigh the drawbacks? • To what extent it will be possible to maintain ....?
- 41. Indicators • Admission • Readmission • Visits • Age/gender • Diagnostic • Comorbidity Transitions and contacts Care cycle • Resolution • Hospital days/yerar 41 Demography Mortality • Intra-hosp
- 44. The paradox of "pilot studies" Pilot studies Real life
- 45. 43% 32% Eur J Cardiovasc Nurs. 2011 Mar 12.
- 46. “Value-based purchasing” The value is measured by considering the "whole process" not every "individual procedures"
- 47. Standardization Març 2009 … and health professionals (mainly physicians) they prefer the arts to science
- 49. Ann Intern Med. 2010;153:167-175.