Fewer hospitalizations for diabetic veterans using VA’s home-based care

By Kathryn Doyle NEW YORK (Reuters Health) - For older U.S. military veterans with multiple chronic conditions, including diabetes, taking advantage of home-based primary care from the U.S. Department of Veterans Affairs (VA) was linked to fewer hospitalizations, in a recent study. Some VA medical centers in the U.S. offer home-based primary care, in which a physician supervises a health care team that provides services in the veteran’s home, rather than through regular clinic visits. Patients are cared for “by a multidisciplinary team of physicians, nurses, social workers, pharmacists and psychologists,” said lead author Dr. Samuel T. Edwards of the Veterans Affairs Boston Healthcare System in an email to Reuters Health. The study didn’t address why home-based primary care was linked to fewer preventable hospitalizations. But Edwards said the program could potentially improve compliance with medications and ensure that patients understood their care plans. It could also improve coordination of social and support services, referrals and specialty care. Edwards and his team used national data on all veterans over age 67 who received a prescription for diabetes medication in 2005 or 2006, had at least one more chronic condition, and were fee-for-service Medicare beneficiaries. All the veterans had been hospitalized at least once in 2005 and 2006 and primarily used a VA medical center offering home-based primary care. Of the 56,608 veterans in this category, 1,978 enrolled in the home-based primary care program, with at least two home healthcare visits between 2006 and 2010. Those who did enroll tended to be older, have more chronic conditions such as heart failure, lung disease, paralysis and depression. Their diabetes tended to be more severe and they tended to live closer to the nearest VA facility offering home-based care. Veterans enrolled in home-based care were almost six percent less likely to be hospitalized in a year than those who did not use it, according to results in JAMA Internal Medicine. “That’s a very large number, and it’s hard to make large improvements in health outcomes,” said Dr. Alex D. Federman. “I think this is a substantial improvement that this program demonstrated, and it also supports findings from some smaller studies from the past few years (that) have shown that home based primary care is effective.” Federman, of the Icahn School of Medicine at Mount Sinai in New York, wrote a commentary published with the results in JAMA Internal Medicine. Many veterans have trouble leaving their homes due to frailty or impairment and, without an in-home visit, would not have access to healthcare, he said. Entering the home, a doctor can provide better-informed care as well, Federman said. “Usually in the office we have only a little sense of the patient,” he said. “The home environment tells us how they are organizing their medicines, which ones they are taking, and gives us a sense of how they’re able to function in the home.” Social factors and mental health issues can also contribute to progression and worsening of disease, he told Reuters Health by phone. “Seeing that firsthand is really powerful, it enables clinicians working as part of the team to be much more effective in delivering care,” Federman said. All veterans enrolled in the Veterans Health Administration Standard Medical Benefits Package are eligible if the qualify clinically and the service is available in their area. Veterans who qualify clinically require skilled services, case management, and assistance with activities of daily living like bathing or instrumental activities of daily living like fixing meals and taking medicines. “The program specifically targets patients for whom routine clinic-based care is not effective, which is often elderly patients with complex, chronic, disabling disease,” Edwards said. Within the VA, home-based care programs are small, which may limit enrollment, he said. There are about 25,000 enrollees in home-based primary care at any given time and the VA has about 5.8 million active users, he said. “It is likely there are many more elderly Veterans with multiple chronic diseases that use the VA than there are HBPC enrollees,” he said. SOURCE: http://bit.ly/1s525vl JAMA Internal Medicine, online September 15, 2014.