1. How IAH House Call Model Works K. Eric De Jonge, M.D. Washington Hospital Center Washington D.C. Campaign for Better Care Webinar June 30, 2010

3. Case – Ms. Alma 2007- 96 yo woman, in wheelchair, with breast/axillary mass, left arm blood clot No doctor in 10 years Uncontrolled HTN, DM, Severe Arthritis Dx: Regionally metastatic Breast CA Rx: Femara, Coumadin, BP meds, PT

4. Ms. Alma 2007-2009 - Home-Base Primary Care –Arrange aides, rehab, INR, meds / DME –31 medical house calls, 23 SW visits –2 admissions to WHC 8/08- MRSA arm abscess, LOS – 2 days 2/09- MRSA gangrene  AKA, LOS- 15 days Goes home very ill, with hospice, 16-hour aides and family Course: Sacral ulcer, infected AKA suture, dysphagia, weight loss,

5. Transport to ER/Office as crises occur Default - Full Code status / life support Progression of functional decline, pressure sore, infected AKA, Dysphagia tests Multiple admissions, ICU?, NHP

6. Ms. Alma –Goals with MHCP team “Stay home” with comfort and safety Allow Natural Death (AND) –Intensive coordination: Acute care, Oncology, Vascular, Optho, Rehab, Hospice, Meds, DME, Aides, Family support –10/09- Still home after 2 years, now bedbound Great Spirit -- “And how are you doing?”

7. Focus on 10% most ill elders = >60% of $$ –“Too sick to go to the office” Mobile MD/ NP/ SW primary care team –About 300 patients per team Full responsibility over all settings, until end of life

8. Independence at Home: Patients 2 or more severe chronic illnesses, plus Functional impairment in 2 or more ADLs, plus Hospitalization and post-acute care (rehab or home care) in the past 12 months

9. Core Staff Roles MD- Initial visit, hospital care, complex Dx / Rx NP- Follow-ups, Urgent visits, education SW- Case mgt. supportive services / counseling Coordinator: Deliver all services and transport

11. Spokes of Wheel Acute / ER care Pharmacy / DME delivery Personal Care aides IP rehab Skilled home care (RN/ rehab) APS/ Legal Hospice Specialty MD / Radiology services

13. Perspectives- Three Legs Mobile Primary Care Community Resources & Supportive Services Environment Support Functional Independence

14. Weaknesses of HBPC Staff and time-intensive –Premium on geography, mobile EHR with interoperability across settings Finding and paying good MDs well Hard to innovate inside large organizations Now-- Need secondary revenue to be viable –HHA, hospice, labs, Radiology, Philanthropy

15. Strengths Trust  clear goals, alliance at EOL Prevent dangerous and high-cost events –Savings for Medicare, share with providers Model for health reform that works –- High-cost elders