Veterans Health Administration

Dr. Milton Havron treats a Veteran patient in his home.

“How inconvenient and needlessly expensive it is for a chronically ill patient who cannot walk to be brought to a clinic by an ambulance crew.

“How much more sense it makes for medical people to go to them. In the patient’s home I am in their milieu, and can better understand how they cope with their illness day to day.“

Dr. Milton Havron is describing VA’s Home Based Primary Care program. He is the director of the program at the Martinsburg, WV, VA Medical Center. And one of VA’s proudest proponents of the program.

“In the patient’s home I can better understand how they cope.”

In a recent letter to the Washington Post, Dr. Havron agreed with a doctor who says “In today’s corporatized, professionally fragmented medical landscape, it is almost impossible for a primary-care doctor to take the time to truly connect with patients and their families.” Dr. Havron’s friendly rejoinder was, “I am blessed, however, to work in a setting that allows just that: the Veterans Health Administration.”

Home based primary care (HBPC), pioneered in the VA system in the mid-1970s, started with a few major centers. Today it has expanded to about 150 programs at VA centers around the country.

It is designed to take care of patients with serious chronic illnesses for whom routine clinic-based care is difficult to get due to geographic barriers or severe physical disability.

HBPC Allows Time for Comprehensive Assessment

As Dr. Havron describes HBPC, “I can spend time getting to know their principal caretakers. I can spot things going on in their homes which may impede their progress. The design of VA’s HBPC program allows me and my staff time to do a comprehensive assessment which is very difficult in the private sector due to time pressure.

“HBPC also serves as an alternative to institutionalized assisted living, allowing the infirm Veteran to stay home. Without regular easily accessible medical care, many of these frail patients will get sick and get admitted to the hospital for prolonged stays.

“While HBPC cannot prevent all such hospitalizations, the statistics tell the story that patients admitted to VA HBPC programs have fewer and shorter hospitalizations, saving on inpatient expenses and sparing the patient much suffering and inconvenience.”

Dr. Havron says that there are many HBPC medical directors around the country doing the same thing he does. “HBPC is a team concept with multiple players, from our head of geriatrics Dr. Elisabeth Sethi, to the midlevels, the RNs, the allied professionals, and our staff.”

Dr. Sethi points out that, “Under Dr. Havron’s leadership, our HBPC program has been one of the fastest growing nationally, supported by VHA rural health grants, by our facility and the VISN (Veterans Integrated Service Network).”

Services Provided to Veterans in Their Homes

HBPC programs generally offer these core services to patients in their homes:

• A medical provider (physician, nurse-practitioner, or physician assistant) to take a history, examine the patient and prescribe a course of treatment
• a registered nurse to act as the provider’s eyes and ears in between provider visits
• a psychologist if counseling is required
• a social worker to untie many a bureaucratic knot
• a pharmacist to help providers prescribe medications in the safest and most effective way
• a physical or occupational therapist to check the home for safety and prescribe exercises for musculoskeletal ailments.

Dr. Thomas Edes, Executive Director of VA’s Geriatrics & Extended Care Clinical Operations, adds, “HBPC is an important part of the future of health care, demonstrating that for those who have the greatest need for frequent care yet face the greatest challenges in access to care, we can increase access, improve quality, and lower total costs of care. The success of VA HBPC contributed to the successful implementation of the Medicare demonstration of HBPC called “Independence at Home.”

“Proud that VA has been a leader”

HBPC also works alongside home hospice services for terminal patients and with specialized home care nurses providing wound care or short-term intravenous drug therapy in the home.

In recent years VA has also been developing telemedicine as a way to bring at-home patients and specialist doctors together.

Home-based primary-care programs can be a refuge where doctors, and their nurse-practitioner and physician-assistant colleagues, can practice traditional personalized medicine while enjoying the benefits of modern communications technology.

“I am proud that the VA has been a leader in this concept,” he said.