The Importance of Home-based Primary Care: Why Older Adults Need It Bruce Leff, MD Professor of Medicine Co-Director, Elder House Call Program Johns Hopkins University School of Medicine Campaign for Better Care Webinar June 30, 2010

Let’s Start with Leo Frail, homebound, 89 years old Limited mobility; walks with walker Needs help with activities of daily living Heart failure, lung disease, arthritis, diabetes, hypertension, etc Admitted 4 times to the hospital last year for heart failure Many medicines prescribed by physicians who have not seen him in years Lives with frail wife who is his caregiver

The Population is Aging and Increasingly Frail % of Older Adults Who Need Daily Personal Care There are ~ 2-3 million older adults with high grade functional impairment Will double in about 15 years

Our Current System Doesn’t Meet Leo’s Needs He can’t get to the office Uses 911 as primary care, goes to the emergency department and is admitted to the hospital repeatedly Treated as a basket of chronic conditions rather than a person with chronic conditions No continuity of care No attention to his quality of life

Our Health Care System is Fiscally Unwell and Unsustainable

Chronic Conditions and Medicare Expenditures Number of Chronic Conditions Percent of Beneficiaries 65+ Percent Medicare Expenditures %66%

Home-Based Primary Care

1.Compassionate, mobile primary care team providing primary and acute care 2.Target the most ill older adults, focus on providing high quality geriatric care and preventing hospitalizations 3.State-of-the-art diagnosis and treatment in the home 4.Coordinate ALL medical and social services 5.Financially viable for providers and for society Key Principles of Effective Home-Based Primary Care Practices

Key Elements of the Home-Based Primary Care Model Subspecialists Radiology Acute, ER, Ambulance Aides, Food, Environment, Legal Counsel, Housing Rehab, HHA, Hospice Pharmacy, Durable Medical Equipment, IV, Oxygen Transportation, Labs Patient MD/NP/SW 24/7 Team Portable HER

Additional Advantages of Home-based Primary Care Provides access to health care and focuses on unique needs of older adults “High touch, high tech” - portable technology expands clinical repertoire of home based physician compared to clinic Seeing the patient in his / her own environment - builds trust, improves diagnosis, develop better care plans House call physicians coordinate services and care better Better integration of caregivers into care plans

Outcomes of Home-Based Primary Care ProgramOutcome Veterans Affairs Home-Based Primary Care ↓ Total health care costs 24% Highest pt satisfaction any VA program -83% Virginia Commonwealth University ↓ Hospital costs 60% Urban Medical Housecalls, Boston ↓ Hospital admissions 29% ↓ Hospital days 34% University of Pennsylvania ↓ Total health care costs 50% ↓ Hospitalizations 64% Philadelphia House Call Program for post- hospital patients ↓ Hospital readmissions 50% ↓ Total health care costs $3,000 to $4,845 per pt Elder Partnership for All Inclusive Care (ElderPAC) at Penn ↓ Medicare hospital days 59% ↓ Medicare care costs 50% Office Without Walls, Nevada ↓ Hospitalizations 27% ↓ Costs by $760 per patient Indianapolis House Call program ↓ Hospitalization 44% for high risk patients with multiple chronic diseases

Summary Population is aging and increasingly frail The current health care delivery system doesn’t meet the needs of older, frail patients and is very expensive Home-based primary care can deliver high quality care and reduce health service utilization and costs