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Home Based Primary Care In place of a clinic visit to a primary care physician (will describe LR model) Interdisciplinary in nature Joint Commission accredited.

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Presentation on theme: "Home Based Primary Care In place of a clinic visit to a primary care physician (will describe LR model) Interdisciplinary in nature Joint Commission accredited."— Presentation transcript:

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2 Home Based Primary Care In place of a clinic visit to a primary care physician (will describe LR model) Interdisciplinary in nature Joint Commission accredited

3 Patient Characteristics (1) Homebound Frail with chronic medical problems Accepting of care Generally geriatric

4 Patient Characteristics (2) Avg age is 80 Medical problems avg Cognitive Impairment of some degree is prevalent If spouse is caregiver, also frail with cognitive impairment Avg income $20,000

5 Patient “Qualifications” Meet the characteristics Live in geographic territory Don’t drive Have a caregiver Have a habitable home Safe environment---substance abuse, violent neighborhood

6 Refferals Formal consults Informal consults Inferred through other needs Self referrals Other patients/caregivers refer

7 Process Evaluation---SW, Psychologist, APN Needs can be met by team resources Patient agrees to limit outside providers All team members assess the patient Treatment Plan is developed in an interdisciplinary team meeting

8 VA Health Care Team APN RN SW Psychologist Therapist RD Pharmacist Medical Support Clerk Physician PATIENT/CAREGIVER

9 Medical Foster Homes Piloted in Little Rock---Judy Karklins, LCSW Adopted as national program Patients must be followed by HBPC Veteran pays for room/board/physical care on a scale according to ADL needs VA vets the homes for safety/suitability

10 MFH (2) Non-institutional care “Age In Place” Family atmosphere Sufficient Income Same criteria as for HBPC

11 Fee Services Home Health Aides Skilled Nursing Service Hospice Therapy

12 Process for Fee Service Order Alert to Community Health Division of HHCS CHN contacts Fee Office for fee payment approval Fee physician approval of care CHN locates agency in Veteran’s area who has availability and faxes orders, pertinent clinical data and fee authorization for payment to agency


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