Home and community-based services coordination for homebound older adults in home-based primary care

Social distancing measures following the outbreak of COVID-19 have led to a rapid shift to virtual and telephone care. Social workers and mental health providers in VA home-based primary care (HBPC) teams face challenges providing psychosocial support to their homebound, medically complex, socially isolated patient population who are high risk for poor health outcomes related to COVID-19. We developed and disseminated an 8-week telephone or virtual group intervention for front-line HBPC social workers and mental health providers to use with socially isolated, medically complex older adults. The intervention draws on skills from evidence-based psychotherapies for older adults including Acceptance and Commitment Therapy, Cognitive-Behavioral Therapy, and Problem-Solving Therapy. The manual was disseminated to VA HBPC clinicians and geriatrics providers across the United States in March 2020 for expeditious implementation. Eighteen HBPC teams and three VA Primary Care teams reported immediate delivery of a local virtual or telephone group using the manual. In this paper we describe the manual’s development and clinical recommendations for its application across geriatric care settings. Future evaluation will identify ways to meet longer-term social isolation and evolving mental health needs for this patient population as the pandemic continues.

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Evaluation of an initiative to improve advance care planning for a home-based primary care service

BMC Geriatrics ◽

10.1186/s12877-021-02035-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Michelle B. Cox ◽

Margaret J. McGregor ◽

Madison Huggins ◽

Paige Moorhouse ◽

Laurie Mallery ◽

...

Keyword(s):

Older Adults ◽

Primary Care ◽

Decision Maker ◽

Care Service ◽

Do Not Resuscitate ◽

Substitute Decision Maker ◽

Home Based Primary Care ◽

Home Based ◽

Before And After ◽

Advance Care

Abstract Background Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP. Methods The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation. Results We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively. Conclusions Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.

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EFFECTIVENESS OF HOME- AND COMMUNITY-BASED SERVICES IN DECREASING HEALTH CARE EXPENDITURE IN TAIWAN

Innovation in Aging ◽

10.1093/geroni/igz038.570 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S159-S159

Author(s):

Ya-Mei Chen ◽

Hsiao-Wei Yu ◽

Ying-Chieh Wang

Keyword(s):

Primary Care ◽

Health Care ◽

Long Term Care ◽

Community Based ◽

Term Care ◽

Care Recipients ◽

Home Based ◽

Number Of Visits ◽

Community Based Services

Abstract Ideally, continuum of care involves wide-ranging health and long-term care (LTC) services. Taiwan’s National Health Insurance scheme and 10-Year Long-term Care Plan attempts to provide universal and fundamental services of continuum care. However, the accessibility of these services for care recipients remains unclear. This study aims to examine the effectiveness of continuum care in decreasing the healthcare expenditure of LTC recipients using home- and community-based services (HCBS). Data collated from the 2010–2013 Long-Term Care Service Management System (N = 77,251) were subjected to latent class analysis to identify subgroups of recipients using HCBS. Subsequently, the 1-year primary care expenditure after receiving HCBS was compared through generalized linear modeling. Three discrete HCBS subgroups were found: home-based personal care (HP), home-based health care (HH), and community-based care (CC). No difference in the number of visits to doctors and the average primary care expenses was observed between the HP and HH subgroups. However, considering physical and psychosocial confounders, care recipients in the CC subgroup recorded a higher number of visits to doctors (β = 3.05, SD = 0.25, p < 0.05) and lower primary care expenditure (β = -98.15, SD = 43.17, p = 0.02) than the other two subgroups. These findings suggest that LTC recipients in Taiwan may obtain better continuum care only for CC service recipients. Additionally, community-based LTC services may lower the cost of health expenditure after 1 year.

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Informal and formal care infrastructure and perceived need for caregiver training for frail US veterans referred to home and community-based services

Chronic Illness ◽

10.1177/1742395309352694 ◽

2010 ◽

Vol 6 (1) ◽

pp. 57-66 ◽

Cited By ~ 16

Author(s):

Courtney Harold Van Houtven ◽

Eugene Z. Oddone ◽

Morris Weinberger

Keyword(s):

Primary Care ◽

Informal Care ◽

Medical Center ◽

Caregiver Training ◽

Community Based ◽

Home Health Services ◽

Home Based ◽

Chi Squared ◽

Us Veterans ◽

Community Based Services

Objectives: To describe the informal care network of US veterans referred to home and community-based services (Homemaker Home Health services, H/HHA, or Home-Based Primary Care, HBPC) at the Durham Veterans Affairs Medical Center (VAMC), including: quantity and types of tasks provided and desired content for caregiver training programs. Methods: All primary care patients referred to H/HHA or HBPC during the preceding 3 months were sent questionnaires in May 2007. Additionally, caregivers were sent questionnaires if a patient gave permission. Descriptive statistics and chi-squared tests were performed. Results: On average, patients received 5.6 hours of VA care and 47 hours of informal care per week. 26% of patients (38% of patients with caregiver proxy respondents) and 59% of caregivers indicated the caregiver would be interested in participating in a training program by phone or on-site. Significant barriers to participation existed. The most common barriers were: transportation; no time due to caregiving or work demands; caregiver’s own health limitations; and no need. Conclusions: Caregiver training needs to be tailored to overcome barriers to participate. Overcoming these barriers may be possible through in-home phone or internet training outside traditional business hours, and by tailoring training to accommodate limiting health problems among caregivers.

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Acute, Post-acute, and Primary Care Utilization in a Home-Based Primary Care Program During COVID-19

The Gerontologist ◽

10.1093/geront/gnaa158 ◽

2020 ◽

Author(s):

Karen A Abrashkin ◽

Jenny Zhang ◽

Asantewaa Poku

Keyword(s):

Older Adults ◽

Primary Care ◽

Care Program ◽

Care Utilization ◽

Advanced Illness ◽

Home Setting ◽

Home Based ◽

Homebound Older Adults ◽

Poor Outcomes ◽

Primary Care Utilization

Abstract Background and Objectives Older adults with multiple comorbidities experience high rates of hospitalization and poor outcomes from Coronavirus Disease 2019 (COVID-19). Changes in care utilization by persons in advanced illness management (AIM) programs during the COVID-19 pandemic are not well known. The purpose of this study was to describe changes in care utilization by homebound AIM patients in an epicenter of the COVID-19 pandemic before and during the pandemic. Research Design and Methods Descriptive statistics and tests of differences were used to compare care utilization rates, including emergency department (ED) and inpatient admissions, acute and subacute rehabilitation, and AIM program utilization during the pandemic with rates 1 year prior. Results Acute and post-acute utilization for enrollees (n = 1,468) decreased March–May 2020 compared to 1 year prior (n = 1,452), while utilization of AIM program resources remained high. Comparing 2019 and 2020, ED visits/1,000 enrollees were 109 versus 44 (p < .001), inpatient admissions 213 versus 113 (p < .001), and rehabilitation facility admissions 56 versus 31 (p = .014); AIM program home visits were 1,935 versus 276 (p < .001), remote visits (telehealth/telephonic) 0 versus 1,079 (p < .001), and all other phone touches 3,032 versus 5,062 (p < .001). Home hospice admissions/1,000 increased: 16–31 (p = .011). Discussion and Implications Our results demonstrate decreased acute and post-acute utilization, while maintaining high levels of connectedness to the AIM program, among a cohort of homebound older adults during the COVID-19 pandemic compared with 1 year prior. While further study is needed, our results suggest that AIM programs can provide support to this population in the home setting during a pandemic.

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