1. Return of the House Call A Breakfast Forum Housecall Providers June 4, 2014

2. The Mission of House Calls 1.Improve the quality of life of homebound patients 2.Improve the quality of life of caregivers 3.Decrease health care costs by enabling patients to remain at home and avoid expensive emergency departments, hospitals and nursing homes Three Reasons for the Decline of the House Call 1.Increased office/hospital based technology 2.Fear of increased liability 3.Financial disincentives

3. Technology is Not a Barrier Liability is Not a Barrier

4. Medicare House Call Codes/Payments 1 Additional 1998 higher level Medicare house call codes 2 IDPA: Illinois Department of Public Aide Shaded payments are most frequently used house call codes Note: Medicare Payments vary by locality. These are for Locality 15. Place of Service Code for Home = 12

5. The Return of the House Call Why? Demographics: Aging of Society Health Care Reform: The Affordable Care Act 1.Readmission Reduction 2.Accountable Care Organizations 3.Independence at Home Medicare and Medicaid Fiscal Crisis Recent evidence of the value of house calls

6. Demographics: Aging Society

7. Exploding Homebound Population!

8. For half of the patients readmitted within 30 days, there was no bill for a physician visit during that time.

9. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial (Naylor, M.D. et al. 2004. JAGS 52:675–84.) Resource Use Among Elderly Congestive Heart Failure: Patients Who Received a Transitional Care Intervention or Usual Care, Six Philadelphia Hospitals, 1997–2001

10. 5/14/09 – 2/18/11 (1 year, 9 months (645 days))  44 Emergency Department Visits (avg 16 days between visits)  27 Hospitalizations—over half required ICU days (avg 25 days between stays) HCP First Visit 3/2/11 (365 Days)  1 ED visit + 1 Hospitalization (May 2011)  Expected: 25 ED visits, 15 Hospitalizations  Following Year : 0 ED, 0 Hospitalizations

11. 1/1/12-12/5/12  17 Emergency Department (ED) Visits  13 Hospitalizations (69 Days)  Multiple rehab stays HCP First Visit 12/5/12  1 ED Visit/1 Hospitalization 12/18/12 (4 days)  0 ED Visits/0 Hospitalizations in 2013  Passed away at home 7/22/13 on hospice

12. End-of-Life Care HomeCare Physicians Patient Deaths 2003-2013 NumberPercentage Total2049100% Home1,52174% Hospital38919% Nursing Home1025% Unknown372%

13. HomeCare Physicians and End-of-Life Care 9/1/12-8/31/13 215 deaths – 79% died at home – 71% where on hospice – Average length of stay 2.1 years – Median length of stay 0.56 years – 25 died in first 30 days 23 (92%) died at home 25.1% of the $556 billion Medicare dollars goes to care in last year of life Riley, Lubitz; Health Services Research 4/2010

14. Average Traditional Medicare per capita Spending, 2009 Source: The Kaiser Foundation

15. Independence at Home Demonstration 1. Focuses on the highest cost Medicare beneficiaries (10% of Medicare beneficiaries with ≥ 5 chronic conditions account for 2/3rds of Medicare spending) 1. ≥ 2 chronic conditions 2. Emergent hospitalization in past year + post acute care services 3. Functional dependence (≥ 2 ADL deficiencies) and frailty 2. Holds IAH provider organizations strictly accountable for three performance standards 1. Minimum savings of 5% 2. Good outcomes commensurate with the beneficiary’s condition 3. Patient/caregiver satisfaction

16. Independence at Home Demonstration Savings beyond 5% are split 80% / 20% with Medicare thereby creating an incentive for greater savings and generating revenue that can be invested in new mobile technologies that generate further savings such as decisional support, point-of- service diagnostic testing and portable therapeutic devices.

17. Medicare/Medicaid Crisis Medicare facing insolvency Medicaid increased from 8% of state spending in FY1985 to 22% in FY2004 overtaking K-12 education as the largest component of state budgets Most rapidly increasing Medicaid cost is for long term care

18. Costs of Care Before vs During HBPC for 2002 (per patient per year) *includes HBPC cost Before HBPC During HBPC Change Total Cost of VA Care $38,228$29,136*-$9,092 (- 24%) P < 0.0001 Hospital$18,868$7026$11,842 (- 63%) Nursing home$10,382$1382$9000 (- 87%) Outpatient$6490$7140$650 (+ 10%) All home care$2488$13,588*$11,100 (+ 460%) N=11,334 $103,048,728