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
Dec 26, 2015
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
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
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,
• 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
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?”
• 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
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
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
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
Perspectives- Three Legs
Mobile PrimaryCare
Community Resources& Supportive Services
Environment Support Functional Independence
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
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