Home (Care) for the Holidays

Keeping your oldest, sickest patients at home not only enhances their dignity, but is a more cost-effective way to care for them. It could even lead to shared savings.

An innovative team-based model of patient care keeps frail and elderly patients at home, reduces costs, builds trust between providers and patients, and reduces emergency department visits.

Fifteen years in, the results are clear.

A study, published in the Journal of the American Geriatrics Society, looks at the middle five years of a program that began in 1999 at MedStar Washington (D.C.) Hospital Center, a 926-bed hospital that is part of the MedStar Health system.

In the late 1990s, K. Eric De Jonge, MD, and George Taler, MD, co-founded what is now known as hospital's House Call program, a hospital-based, team approach that cares for frail and elderly patients in the D.C. area.

"When we started this program, we began a new geriatrics division and talked to the CEO and CMO … and they gave us 2–3 years to break even," says De Jonge. "What became clear is the need. We got 20 new patients per month without marketing and it grew rapidly."

Now, 15 years later, the House Call program cares for approximately 630 patients, says De Jonge. To be eligible for the program, patients must be over 65, have some form of insurance, live within the nine zip codes the MedStar Washington serves, and have trouble getting out of the home.

"These are folks with multiple chronic illnesses and have a high risk of hospitalization and social needs," says De Jonge who also aims to promote not just patient health for this population, but he also wants these patients to be treated with dignity so they can continue to live in their own homes.

Team-based Approach
Two teams take care of MedStar Washington's House Calls' patients. De Jonge says each team includes 10 people, with two people who can float between teams: an LPN and a business manager.

"There are about two and a half teams now," he says. "There are two MDs, two NPs, two social workers, two office coordinators, and including the LPN and business manager, that team is the hub to providing care to about 300 patients."

The first visit with a patient is usually done by one of the doctors and takes about 90 minutes. After that, NPs will keep up with the patients as well as social workers, who De Jonge says provide "tremendous value." Social workers have been fairly easy to find and are typically a good fit, says De Jonge.

Other care team member slots are harder to fill.

"Finding a skilled and dedicated workforce is a major challenge to doing this kind of care," he says. "The financial playing field is not level. Primary care geriatricians, which there are not many anyway, are also not paid a lot, and they have to be willing to leave the comfort of their offices."

There is a nationwide shortage of geriatricians. According to the American Geriatrics Society, there are currently only 7,500 in the U.S. It projects the country will need close to 30,000 geriatricians by 2030, when one in five Americans is eligible for Medicare.

The benefit of creating a team-based approach to care for the frail elderly results in real savings. According the study, led by De Jonge and Toler, patients cared for in their homes had 17% lower Medicare costs.

"The team is the hub of the wheel," says De Jonge. "The wheel includes medication delivery, medical equipment, PT, OT, skilled nursing, transportation, emergency room care, acute hospital care, inpatient rehab, home hospice, inpatient hospice, food, utilities, legal support, [and] adult protective services. It's a comprehensive one-stop stop."

Some hospital leaders I've talked to question taking on the responsibility of providing patients with needs that extend beyond the office walls. Participants in MedStar Washington's House Calls program do not even step into a clinic or doctor's office. However, it's because De Jonge and his team know that social factors play an indirect and direct role in a patient's health, and sloughing off the responsibility of patients' ancillary needs is short-sighted.

Lower Cost
Critical access hospitals and physicians who work in urban areas recognize that connecting patients with social services can often be a critical linchpin. The study shows that despite having similar rates of mortality, the control group was more expensive to take care of than the group of beneficiaries who had home-based care.

De Jonge says a key factor to helping families is giving them one number to call for any issue that arises.
"We work to prevent medical and social crises," says De Jong. "You have to keep it very simple for patients and families when they're dealing with illness."

The House Calls program is staff 365-days a year, 24/7. That kind of accessibility builds trust and loyalty to the health system, says De Jonge.

"It's crucial that the patient and family see you as a team," he says. "When you're making the effort [to see them in the home], there's gratitude and trust that is built up toward MedStar Health."

In addition to reducing health care costs, the study of 722 House Call patients, showed fewer emergency room visits, hospitalizations, skilled nursing facility stays, and specialist visits.

Expanding Home-based Care
MedStar Washington's House Calls program began with two geriatricians recognizing the need in its service area 15 years ago. Today, the program, while still only serving the frail elderly in less than a dozen zip codes, is part of a larger demonstration project that CMS started in 2012.

The Independence at Home (IAH) project includes 17 sites that are offering home-based care services. De Jonge says there six quality metrics that CMS is measuring to determine if sites are hitting the target of reducing costs by at least 8%. He says MedStar Washington is meeting those metrics and will find out in February if the results of the first year will net the hospital any savings.

"If IAH succeeds, we'll be getting shared savings… 80% would go to the provider, MedStar," he says.

That could help cover the costs of operating the hospital-based program, which De Jonge says operates at about a 20% gap every year, but as De Jonge says, "the benefits outweigh the costs."