1. The Outcomes and
Reimbursement in
Home Care
Joan Escarrabill MD
Chronic Care Program– Barcelona Esquerra.
Hospital Clínic (Barcelona)
Ankara, November 15th 2013
1
Master Plan for Respiratory Diseases (PDMAR) & Home
Respiratory Therapies Observatory (ObsTRD). FORES.
Ministry of Health (Catalonia)

2. Agenda
Context
Home
care
Alternatives
Outcomes
2

3. Historically, most health care was
provided in the home
N Engl J Med 1997;337: 1815-20.
% house calls in patient–physician encounters
40
40
30
10
20
%
0.6
10
0
3
1930
1950
1980

4. Types of visits in Primary Care
Home care
1%
2005
Phone contact
0%
Primary Care Visits
42,000,000
41,000,000
Visit
99%
40,000,000
39,000,000
38,000,000
37,000,000
Home care
2%
36,000,000
2009
35,000,000
34,000,000
2005
2006
2007
2008
2009
Visits PC
Visit
94%
Phone
contact
4%

5. Home care Primary Care ICS (2010)
Who cares at home?
Place of care
6% 3%
2%
5%
30%
Mainly outof-hours
63%
91%
Mainly long-term
care (ATDOM)
Doctors
Nurses
Social workers
Home care support
Office visits
Phone calls
Total number of consultations: 33.420.762
Home visits

6. Home oxygen therapy (1885)
6

7. There is no place like home
There are clinical reasons
to avoid hospitalization
Overmedication
Social isolation
Adverse events
In the hospital
Inactivity
7

8. Different services in one place
Out-of-Hours
• Nursing care
• Out-of-Hours Service
Support from discharge
• Hospital at home
• Transitional care
Long-term care
• “Preventive”
• Specialized
Procedures at home
• Drug administration

9. Definition: a difficult task
Aten Primaria 2002;30:304-309
You can set the standards
of care based on criteria
Criteria
Definition
Duration of care
Short < 15 days or long > 60 days
Complexity
Devices, decissions, daily life support
Intensity
Number of visitis per day
Speed ​of response
Emergencies / Support from discharge
Coverage
24/7/265 vs working hours

10. Definition: a difficult task
Out-ofHours
Hospital
at home
Transitional care
Long-term
(ATDOM)
Long-term
(Specialist)
Procedures
Duration of
care
Short
< 15 days
< 60 days
> 60 days
> 60 days
Days
Complexity
Very low
Low
Low
Low
Very high
High
Intensity
Once
High
Low
Once a
month?
Daily
(twice/day?)
Once a
week ?
Speed ​of
response
Same day
High
Low
Scheduled
Immediately
Quick
Coverage
Out of
working
hours
24/7/365
Working
hours
Working
hours
24/7/365
24/7/365

11. From transitional care to long-term care
Primary care
Acute
care
Hospital
at home
Long-term care
Transitional care
Rehabilitation
Palliative care
Specialised long-term care
Home mechanical ventilation
Nutrition (enteral/parenteral)
Peritoneal dialysis

12. From transitional care to long-term care
1
It is often difficult to draw the
line between transitional care
and long-term care
Primary care
Long-term care
Transitional care
2
Rehabilitation
Palliative care
Specialised long-term care
It is not easy to define the role
of generalist and specialist
Home mechanical ventilation
Nutrition (enteral/parenteral)
Peritoneal dialysis

13. Evaluation of home care
From
Products
To
Number of visits
Phone calls
Admissions
….
Services
Meet the needs of patients according
to local resources

14. Agenda
Context
Home
care
Alternatives
Outcomes
14

15. Home care strategies
1
Home care from
Primary care
Post-diascharge &
Hospital at home
2
3
4
Long-term &
Integrated care
Long-term &
HMV
5
15
Palliative care

16. 1
Home care from primary care services
Aten Primaria 2003;31:473-9
Main protocols
Pressure ulcers
End-of-life
Bedridden patients
Pain
Main problems
Lack of time
Scarce social resources
Poor coordination
Nursing
leadership

17. 2
BMJ 2005;329:315-20

18. COPD: Hospital at home
22% refuse
Escarrabill J.
Eur Respir J 2009; 34: 507–512

19. Hernández. Eur Resp J 2003;21:58-6.
Age: 70.8 9.8 years
FEV1 1.1 0.5 l.
Home care
Convencional
Mortality (%)
4,1
6,9
Readmisions (%)
20
27,7
Visits ER
0.13 (0.43)
0.31 (0.62)
0.01
LOS hospital (days)
1.71 (2.33)
4.15 (4.1)
< 0.001
16.5
47.5
< 0.001
7.5
0.03
% admissions > 3 days
LOS home (days)
1.56 (1.31)
Phone calls
2.33 (2-05)
Satisfaction
19
3,56 (1-14)
Home visits
8.0
p

20. Intervention effects
Conventional tharapy
Home care
Cost = 38% lower in home care
Hernández C. Eur Resp J 2003;21:58-6

21. 3
Eur Respir J 2006;28:123-30
Función respiratoria
Co-morbilidad
Problemas sociales
Valoración
global
Integrated
care
Educación (autocuidado)
Deshabituación tabáquica
Conocimiento de la enfermedad
Tratamiento inhalatorio
Actividad física
Signos y síntomas de alarma
21
Programa de
asistencia
personalizda
Coodinación entre los
diversos dispositivos
asistenciales

22. Long-term follow up by specialists in LTOT
Chnages related to home care
20
15
Chest 2001; 119:364–369
10
5
0
ER visits
Admissions
Home care
Positive inpact of
nurse/respiratory therapist +
telephone + home visit
LOS
Control

23. 4
Chest 2005; 127:2132–2138
Benefits of “package of care”:
assessment + follow up +
home support
Protocol

24. Eur Respir J 2010; 35: 310–316
5,4
Calls/patient/year
6%
Requiered home care
25/188 no mechanical
fault was identified
13 patients were either found to
be unwell or required hospital
admission

25. Systemaic follow-up
Population: 291.500.000
25
Escarrabill J. Breathe 2009;6:37-42.

26. 26
Escarrabill J. Breathe 2009;6:37-42.

27. PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238





Grups petits de pacients.
Seguiment curt
Variabilitat terminológica
Diferents intervencions
Orientats a malalties – poc holístic
27
No queda clar si els efectes es relacionan
amb la telemonitorització (e-Health) o
amb el canvi d’estratègia assistencial

28. PLoS ONE 8(8): e71238. doi:10.1371/journal.pone.0071238
“Digital Health Divide”
Hi ha grups de pacients que no estan
prou representats en els estudis:




28
Multimobilitat
Trastorns cognitius
Problemes socials
Discapacitats

29. Pinnok et al. BMJ 2013;347:f6070 doi: 10.1136/bmj.f6070
Risc d’ingrés
29

30. Journal of Telemedicine and Telecare 2012; 18: 211–220

31. 5
Gómez-Batiste X et al. J Pain Symptom Manage 2010;40:652-60
Home care support teams

32. Gómez-Batiste X et al. J Pain Symptom Manage 2006;31:522-32
Health Care Interventions
3%
9%
34%
26%
14%
n=395
32
Home visits
Hospital admission
GP Visit
14%
Phone call
Outpatient clinic
Others

33. Agenda
Context
Home
care
Alternatives
Outcomes
33

34. NEJM 2010;363:2477-81
Value
34
=
Outcomes
Cost

35. The Outcome Measures Hierarchy.
NEJM 2010;363:2477-81
• Time to recovery.
• Desutilities
• Sustainability of health
• Long-term consequences

36. Focus on results
Some mistakes can be made speaking of results
1
Believe that the results of the pilot studies
can be extrapolated automatically
2
The results must to be good in the full process
3
Average approach is harmful
4
The time, from the point of view of
patients, is not process is a key result.

37. Home care evaluation
Health
System
Sustainability
Population Impact
Specific
program
Coverage
Specific objectives
Patient
Patient experience
Health results
37

38. NEJM 2013;368:201-3
38

39. Patient experience (i)
Time
Resolution
capability
Co-participation
Information
39
• Waiting
• Response
• Resolution
• How many professionals are
involved to solve the problems?
• Several options
• Decission-making process
• Deliberation
• Intelligible
• At the right time

40. Patient experience (ii)
Utility
Interference
Benefit
Maintenance
40
• How much was useful…
• Inconveniences that generated the
activity in their daily lives
• Will the benefits outweigh the
drawbacks?
• To what extent it will be possible to
maintain ....?

41. Indicators
• Admission
• Readmission
• Visits
• Age/gender
• Diagnostic
• Comorbidity
Transitions
and
contacts
Care cycle
• Resolution
• Hospital
days/yerar
41
Demography
Mortality
• Intra-hosp

42. BMJ 2012;345:e6017
42

43. BMJ 2012;345:e6017
43

44. The paradox of "pilot studies"
Pilot
studies
Real life

45. 43%
32%
Eur J Cardiovasc Nurs. 2011 Mar 12.

46. “Value-based
purchasing”
The value is measured by
considering the "whole process"
not every "individual procedures"

47. Standardization
Març 2009
… and health professionals
(mainly physicians) they prefer
the arts to science

48. 48
JAMA 2013;309:355-363

49. Ann Intern Med. 2010;153:167-175.