Robert M. Kaiser, MD, VA “Meet the Expert” Breakfast Session, AAHCM Annual Meeting, May 2015

Fiscal Year 2015 Top 10 VHA Standards and Guidance for HBPC

1. HBPC Special Population PACT is here and requires HBPC teams to have a PrimaryCare Provider who visits the Veteran in his or her home, along with a full complement of clinical interdisciplinary care team members consisting of a Pharmacist, Rehabilitation Therapist, Dietitian, Social Worker, Nurse Care Manager (may have multiple managers on a team), Psychologist, and a Medical Director. Additional team members may be included but are not required.

2. PACT Compass measures and targets for HBPC are:

  • PACT 13- % PC patients enrolled in HT (1.6% or higher)
  • PACT 15- % of PC patients in Primary Care Mental Health Integration (PCMHI) (No target)
  • PACT 16- Ratio of non-traditional encounters (20% or higher)
  • PACT 17- Team 2 day post d/c contact (75% or higher)
  • PACT 19- Provider Continuity (Target 77% or higher)

3. HBPC patients should remain in the HBPC PCMM PACT team during episodes of inpatient stays or other absences beyond 16 days, although a discharge from the HBPC information systems is required to end an episode of active direct HBPC care and non-institutional care census. These systems (PCMM and HBPC Information Systems) have separate functions and meanings for the term “discharge”. A discharge from the HBPC Information systems means that an active episode of home care has concluded. This halts the active HBPC plan of care and other timed clinical care responsibilities involved in active clinical home care. A discharge from PCMM or the HBPC Special Population PACT team means that the Veteran is no longer receiving coordination or primary care services from the HBPC PACT team (examples: veteran expired or Veteran returned to outpatient clinic or other Special Population PACT team).

4. External Peer Review Program (EPRP) HBPC pilot measures for Nutrition Assessment and care plan follow up, and Environmental Assessment and care plan follow up have been converted to formal measures as of Fiscal Year 2015 beginning of the second Quarter. New National Targets of 95% have been set for the 5 of the EPRP measures:

  • hc19- Current medication profile received/sent to patient within 1 day prior to or with 7 days after the most recent home visit by nurse or clinician
  • hc25- Patients with caregiver strain assessment using Zarit Burden scale;
  • hc29- Nutrition/hydration assessment by registered dietitian within 30 days;
  • hc31- Environmental safety/risk assessment by rehab therapist within 30 days;
  • hc33- Medication management plan review by a pharmacist quarterly

5. New HBPC Non-Institutional Care Census Targets have been published in the Electronic Technical manual Nic1 (HBPC Average Daily Census)

  • VISN targets and Facility recommendations are based on analysis of each organization’s Veteran user population using Medicare criteria for the Independence at Home (IAH) demonstration model. The targets are based on an overall 5 year census goal, initially estimating a conservative 20% of the IAH eligible Veterans not currently being served by HBPC.

6. HBPC Received a waiver for the GSA Utilization criteria for 15 Days used or Monthly Mileage requirement for Government Vehicle Utilization. HBPC staff are to maintain trip logs, documenting at least 15 trips (patient visits) per month to meet national HBPC specific utilization standards.

7. HBPC is encouraged to use the Electronic Waiting List. The waiting list for HBPC is used nationally and locally to help identify unmet demand and support future resource and program expansion planning. A consult for HBPC should be reviewed for eligibility within 7 days. Patients will be placed on the EWL immediately once eligibility is verified and a determination is made that the service cannot be provided. It is strongly encouraged to maintain an EWL for unserved HBPC locations.

8. HBPC continues to be exempt from using Appointment Management, advanced scheduling and scheduling grid tools.

9. Joint Commission: New 2015 standards for Home Oxygen were published and require:

  • Conduct oxygen safety risk assessment before starting oxygen therapy and when home care services are initiated to include: presence of smoking materials, other fire risks (open flames), functioning smoke detectors.
  • Re-evaluate risks at intervals established by organization. Unsafe practices establish intervals.
  • Inform and educate patient/family about findings of safety assessment, causes of fires, fire risks for neighboring buildings, and recommendations to address the identified risks.
  • Assess comprehension of identified risks and compliance with suggested recommendations.
  • Implement strategies to improve compliance when unsafe practices are observed. Notification of LIP ordering the oxygen.

10. New Team Conference clinics stop code (673) can be paired with an HBPC Home Visit primary code (will not generate a bill/copay or VERA visit) that can be used when you meet AMA standards for Team Conference CPT codes 99366-99368 or Care Plan oversight 99375. This workload will flow into the CDW for physician productivity.

Source: Darlene Davis, National HBPC Program Office, Department of Veterans Affairs, May, 2015

HBPC Fact Sheet

  1. Home Based Primary Care is health care services provided to Veterans in their home. A VA physician supervises the health care team who provides the services. Home Based Primary Care is for Veterans who have complex health care needs for whom routine clinic-based care is not effective.
  2. HBPC provides longitudinal comprehensive, interdisciplinary care to veterans with complex chronic disease.
  3. Core Interdisciplinary team: Medical Director, Primary Care Provider (MD, NP, or PA), Nurse, Social Worker, Rehabilitation Therapist, Dietitian, Pharmacist, Psychologist
  4. Home Based Primary Care can be used in combination with other Home and Community Based Services.
  5. HBPC Population data:(Source: HBPC Master Files FY 2014)
  • Average 19 diagnoses and 15 active medications
  • 96% male
  • More than 8 chronic conditions, on average
  • 24% annual mortality
  • 48% dependent in 2 or more Activities of Daily Living (ADL)
  • 47% married; 30% live alone
  • Caregivers: 30% limited ADL
  • Mean duration in HBPC: 315 days
  • Average 3.1 visits/month; 28 visits/year
  1. Disease Prevalence in Population(Source: VA Decision Support System Report, Fiscal Year 2014, Primary Care, HBPC Cohort):
  • Hypertension 89%
  • Coronary Artery Disease 62%
  • Diabetes 50%
  • Depression 48%
  • Dementia 45%
  • Heart failure 35%
  • Cancer 30%
  • Substance abuse, including tobacco 30%
  • Anxiety 25%
  • PTSD 16%
  • Schizophrenia 13%
  1. Outcomes(Source: Edes et al., J Am Geriatr Soc 62:1954–1961, 2014)
  • HBPC helps shift care from institutional to home and community settings
  • Between 2000 and 2012:
  • # of Veterans aged 85 and older tripled
  • HBPC census increased from 7,300 to 30,000 -- 310% increase
  • VA-provided nursing home care census rose only 20%, from 30,700 to 36,000.
  • In a 2007 analysis, HBPC enrollment was associated with reductions in VA hospital bed-days of care (59%), nursing home bed-days of care (89%), and 30-day hospital readmissions (21%)
  • Study of 6951 HBPC and Medicare dually enrolled Veterans
  1. 13.4% annualized reduction in total combined VA + Medicare costs (not adjusted for frailty or VA care differences)
  2. 16.7% reduction in VA costs
  3. 10.8% reduction in Medicare costs
  4. 25.5% reduction in combined VA + Medicare hospital admissions and 36.5% reduction in combined hospital days, contributing to a combined VA + Medicare cost net reduction from $45,980 to $39,796 per patient per year including HBPC costs ($9,116/patient per year)

Prepared with the assistance of Darlene Davis, National Program Manager, Home Based Primary Care Program, Department of Veterans Affairs,Dayna Cooper, Chief, Non-Institutional Care, Department of Veterans Affairs, and Thomas Edes, Chief, Geriatric Operations, Department of Veterans Affairs, May 2015

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