1. Bright Spots in the Health Care Landscape that Imagine a Better System: Home Centered Care Thomas Cornwell, MD tcornwell@hccinstitute.org April 16, 2016

3. Emergency Dept VisitsHospitalizations/Days 2007-129716 / 156 201324 9 / 54 Total 2007-13121 (Avg 17 per year)25 / 210 (Avg 3.6/30 per year) Patient first seen 11/22/13 MedStar Washington DC House Call Program: 722 patients vs. 2,161 controls over 2 years: ↓ Medicare costs 17% ($8,477 per patient, $6.1 million total) De Jonge, et al. JAGS 10/14 Veterans Health Administration’s Home-Based Primary Care Program: 6,951 dually enrolled in VA + Medicare: ↓ total costs 13.4% (↓ VA 16.7% / ↓ Medicare 10.8%); ↓ Hospitalizations 25.5% Edes, et al. JAGS 10/14 20145 2 / 9 201510 Independence at Home Medicare Demonstration Year one overall $25 million savings; $3,070 savings/beneficiary ↓ hospital readmissions and emergency department use ↑ 48 hour hospital f/u; Medication reconciliation; Advance Directives

5. Quality End-of-Life Care: Cost of End-of-Life Care 25.1% of Medicare’s $556 billion goes to care in last year of life Riley, Lubitz; Health Services Research 4/2010 2000 to 2009: ↑ deaths at home 30.7% → 33.5% / ↓ at hospitals 32.6% → 24.6%, ↑ hospice 21.6% → 42.2% BUT: – ↑ ICU last month 24.3% → 29.2% – ↑ Hospitalizations last 3 months of life 62.8% → 69.3% – ↑ Short hospice stays (<3 days) 22.2% → 28.4% (40.3% preceded by hospitalization with ICU stay) Teno; Change in End of Life Care for Medicare Beneficiaries JAMA 2/2013 2015 HomeCare Physicians’ End-of-Life Care: 230 deaths 80% (184) died at home 76% (175) where on hospice Average length of stay 1.9 years; Median LOS 1.2 years