More promise for home-based primary care.

A75-year-oldman livesaloneandstruggles tomanagehisheart failure, diabetesmellitus, hyperlipidemia, and chronic arthritis. He is prescribed 12 medications, including some he must take or inject 3 times a day. He cannot walkmore than 30 feet withoutdiscomfortandrarely leaves home. Undertreated depression compounds his problems, contributing to inconsistent medication use and frequently missed appointments with his primary care physician and cardiologist. Not surprisingly, his diabetesmellitus is poorly controlled, andhis heart failure decompensates often, necessitating hospitalization 3 to 4 times a year. This scenario represents oneof the almost 2millionmedically complex, chronically ill, and functionally disabled older adults who challenge clinicians and health systems. In addition to functional impairments and medical and psychiatric complexity, various socioeconomicdeprivations, suchaspoverty and isolation, increase their risk for hospitalization, debility, and death. TheVeteransAdministration (VA)has long recognized the imperative toaddress thevariedpsychosocialandmedicalchallenges to improving outcomes for this population that is too sick to come to a typical ambulatory clinic. In 1972, it established a Home-Based Primary Care (HBPC) program to address the long-term needs of complex chronically ill and disabled patients, including those near the end of life. Similar to non-VAHBPC programs,1,2 the VA’s programprovides coordinated, patient-centered care for patients at high risk for hospitalization by bringing interdisciplinary teams of physicians, nurses, social workers, physical therapists, and others to the patient’s home.3 Yet, despite HBPC’s intuitive appeal, it has lacked a robust body of research to help drive evolution andadoptionof themodel, and the limited findingshavebeen mixed.One randomized trial completed in 1998byHughesand colleagues4 foundthat, amonghomeboundveterans,VAHBPC reducedhospital readmissions only for themost severely disabled and only by a small amount. Findings fromother investigationsarecircumspectowingtomethodological limitations.5 However, the body of research just took a promising step forward. In this issueof JAMAInternalMedicine, Edwards and colleagues6 report outcomes for a nationwide sample of older veterans who received their medical care through the VA’s HBPCprogramor throughstandardoutpatientVAcare in 2005 and 2006.All patientswere 67 years or older andhaddiabetes mellitus with comorbidities and a hospitalization in the prior year. Because outcomes could be biased from the nonrandom selectionof patients forHBPC, the investigators used a sophisticated econometrics technique, instrumental variable analysis, to account for observed and unobserved differences betweenHBPCandnon-HBPCpatients, inessenceapproximating the conditions of a pragmatic randomized clinical trial. After a comprehensivevalidationof theiranalyticapproach, theycompared1-yearhospitalization ratesand founda5.8%absolute reduction in hospitalization risk for HBPC patients. Several features of this study are worth noting. First, the findings stand in contrast to thoseof the randomized trial conducted by Hughes et al,4 which showed no overall reduction inhospitalizations in the target population.While direct comparisons between these 2 studies should be avoided because they involved different study designs and inclusion criteria, taken together their results suggest that HBPC has evolved within the VA system and on average generates net reductions in hospitalizations for high-risk patients. Second, the study provides an estimate of the effect of HBPC in the context of typical clinical practice and is a more realistic estimateof the effect ofHBPC thana randomized trial conducted under tightly controlled conditions could provide. Moreover, as an average of the effect, it represents both the successes and failures of HBPC andholds out the promise of HBPC’s yieldingmajor reductions in acute care use for certain groupsofhigh-riskpatients through improvements inpatient targeting and caredelivery. Indeed, theremayhavebeen considerable variation in the way HBPCwas delivered across the HBPC programs in this study. The VA publishes guidelines for HBPC but allows flexibility for program operation locally.3 Third, the investigators sought to approximate the populationofpatientswhowouldqualify for IndependenceatHome Demonstration–coveredHBPCservices and in theprocessmay have underestimated the effect of HBPC on eligible patients. The Independence atHomeDemonstrationprogram is a Centers for Medicare and Medicaid Services project of HBPC for chronically ill Medicare beneficiaries who are homebound. Medicare defines homebound patients as those who, because of illness or injury, need the aid of supportive devices, special transportation,orassistance fromanotherperson to leave their home or who have a condition for which leaving the home is medicallycontraindicated.7Homeboundpatientsareatgreater risk forhospitalizationbynatureof theseverityof their chronic conditions and their reduced access to health care. Because Edwardsandcolleagues6couldnotdeterminehomeboundstatus using claims andelectronicmedical recorddata, theymay haveunderestimatedtheeffectofHBPCforpatientswhowould quality for it under Medicare. Home-Based Primary Care harks back to a nostalgic time whenphysicians forgedcloseand long-termrelationshipswith their patients and their families because they routinely cared for them in the home during times of illness. The increasing specializationand institutionalizationofmedicinehelpedbring the practice of routine home visits to an end. The current feefor-service reimbursement structure is insufficient to accommodate the time-intensive nature of caring for this high-risk population,which involvesunbillablecarecoordinationbyteleRelated article page 1796 Research Original Investigation Home-Based Primary Care and ACSC Hospitalizations