Hello everyone, and welcome to the Fresh Focus Podcast. I’m Kerri, one of your Marion VA healthcare system Dietitian Nutritionists. I am also a certified diabetes care and education specialist, a certified specialist in gerontology, and a Home-Based Primary Care Dietitian. In today’s episode, I am going to provide you with some information on one of our programs at the VA, Home Based Primary Care or HBPC for short.

Are you a Veteran or know a Veteran that has a chronic medical condition(s) such as Diabetes, Parkinson’s, Chronic Obstructive Pulmonary Disease or COPD, Cancer, Hypertension, ALS, or other chronic condition? Are you a Veteran or do you know a Veteran that has a hard time getting out of their home for their medical appointments? You may want to listen closely to this podcast if you answered yes to either of these questions or even both.

HBPC is for Veterans that have complex and chronic disease(s) for which routine clinic-based care may not be effective. HBPC is known as a primary care clinic on wheels which is where we come to your home for your primary care needs versus you coming into the clinic.
We focus on Veterans that not only have chronic disease but also for those that have had two or more hospital admissions or emergency room visits in the last six months, have had multiple unscheduled visits, or for Veterans that have missed scheduled clinic appointments due to maybe not being able to get to the clinic d/t their travel needs.

HBPC focuses on Veterans that have medical, social, behavioral and/or mental health conditions. We can assist with improving quality of life through symptom management, palliative care measures, and we can meet the challenging needs that a Veteran and/or caregiver might have. We will provide support to meet these needs. HBPC is here to help!

Currently there are 139 HBPC programs nationally in over 350 locations, with an average census ranging anywhere from 80 to 1000 Veterans. HBPC teams currently serve 2-4% of the VA population and the average Veteran enrolled in HBPC has 19 medical diagnoses and is on 15 medications. 48% of HBPC Veterans are dependent in two or more of their Activities of Daily Living which may include bathing, eating, dressing themselves etc, and out of all these Veterans 47% are married with 30% living alone. And about 96% of these Veterans are males.

Not only is HBPC convenient for patients, but it is also cost effective. In 2014, the HBPC program led to 36% fewer VA and Medicare hospitalizations with 25% fewer admissions and 12% lower VA and Medicare costs, including HBPC costs. A Medicare demonstration showed 8400 medically complex disabled Veterans enrolled in VA HBPC programs saved $35 million in the first two years, which is an average of $2100 per Veteran per year.

We want to emphasize that HBPC is NOT Medicare Home Care or Home Health as others call it. HBPC does not require a skilled level of care such as physical therapy, nursing, occupational therapy, etc as Medicare Home Care does, HBPC does not require a Veteran to be strictly homebound as Medicare Home Care does, and HBPC accepts a decline in status as Medicare Home Care expects improvements. Overall HBPC increases access for our Veterans and helps to improve their quality of life.
There are certain criteria that a Veteran must meet to be enrolled in the HBPC program, some of which I have already touched on. Additional criteria include a safe environment for the team to visit. HBPC should also be the main primary care provider for the Veteran and the Veteran and/or caregiver must agree to the program and be willing to work on goals that are set by the Veteran and HBPC team. Discharges may occur when the Veteran meets their goals, the Veteran’s needs exceed what HBPC can do for them, the Veteran and/or Caregiver ask to be discharged or the Veteran moves out of the area that the HBPC program provides care to. If a Veteran is discharged from the program, they will return to the clinic for their care. If the Veteran moves out of the catchment area. a transfer to another HBPC program can be completed with the assistance of the HBPC team if there is an HBPC program available in the area they are moving.

So, now we know what HBPC means, what it can do for Veterans, the criteria, and some other facts, but who makes up the Interdisciplinary Team for HBPC? The HBPC Interdisciplinary Team is made up of several disciplines. Some HBPC teams may have only one team where the current program at the Marion VA has six teams. The Medical Director is the physician that oversees the care of all Veterans across their assigned sites of care. The HBPC Program Director’s role is to manage the program across all assigned sites of care. Each team within the HBPC Program will have a Primary Care Provider, Registered Nurse, Registered Dietitian, Social Worker, Rehabilitation Therapist which is usually a OT or PT, Clinical Pharmacist, and Psychologist or Psychiatrist assigned. The number of disciplines on each team depends on the number of Veterans enrolled in the program. The Primary Care Provider, which is a Medical Doctor, Physician’s Assistant, or Nurse Practitioner, their role is overseeing the care of Veterans assigned to their team. The Registered Nurses are the Primary Care Managers for the Veteran and whom the Veteran will be seeing the most on the team. The Registered Dietitian’s role is to assess the Veteran’s nutritional needs. The Social Worker’s to assesses the Veteran’s mental, behavioral, and social needs. The Rehabilitation Therapist determines the Veteran’s physical, and rehabilitation needs and addresses them as necessary. The Clinical Pharmacist’s role is to provide direct Veteran care and medication services to their assigned Veterans. The pharmacists do not complete home visits. The Psychologist or Psychiatrist is the primary mental health care providers for their assigned Veterans. All disciplines must see the Veteran at least annually in the home in order for the Veteran to be able to remain in the program except for pharmacist or psychologist or psychiatrist. HBPC is an Interdisciplinary approach to meet the Veteran’s needs as a team. Our focus is the Veteran, and the team is there to encourage and educate the Veteran to meet their goals and needs.

As a Dietitian that is part of the HBPC program team, we assess the Veteran’s nutritional status. We will ask you questions about What have you been eating? Do you have any concerns about having food in your home? We will also look at your labs, review your blood sugars if you have diabetes, and we will complete a hands-on assessment, with what we call a nutrition-focused physical exam. We assess the Veterans for malnutrition, you might have lost some weight and some muscle mass and if so, we need to address that, you may desire weight loss which we can help with then again you may not desire weight loss but need some help with better access to food. We want to help you to reach your goals by being there to educate and support you. I have worked as a HBPC dietitian since 2010 there have been so many veterans that I have been privileged to care for one veteran started with HBPC in June 2018 he was 97 years old at the time I remember informing him at one of our home visits that his HGBA1C level was elevated and in the prediabetes range he was concerned about this and asked what he could do to prevent his HGBA1C level from increasing to where he might have the diagnosis of Diabetes. I informed him of dietary changes that he could make, and he actually worked on these and was able to decrease his HGBA1C and was never diagnosed with diabetes. Due to his age he also struggled with losing weight and a NFPE showed muscle wasting and subcutaneous fat loss. I provided recommendations for adding in healthy calories and protein to his diet and eventually ordered a supplement and he was able to maintain his weight for some time. Unfortunately, this veteran passed away this year in May at the age of 103. Him and his wife were married for 76 years, and they had no children. They always praise the VA and the HBPC team for taking such good care of him and helping him remain at home through the end of his life.

Another HBPC patient I worked with just with making dietary changes and encouraged closer monitoring of his blood glucose levels and blood pressures and working closely with his providers to help better control of his diabetes. This veteran reached his goals with HBPC his blood sugars blood pressure goals and was able to be discharged from HBPC and is able to go back to the clinic and he was able to go back to work.

Not only does HBPC help with the Veterans physical well-being we can also help with emotional and mental well-being. I have a veteran who was living at home and had a caregiver who was coming in and take care of him a daily basis. This veteran has a TBI, dementia, and diabetes along with other comorbidities. I went to see him on a home visit one time and his caregiver was present I typically would check that he had adequate amount of food in the home he had his CGM sensor in place which is continuous glucose monitor that his sensor and reader was charged that he had taken his meds out of his planners, look at the wounds on his legs and make sure he had taken his insulin by counting his insulin pens. Later that week on a Saturday we found out that his caregiver had unexpectedly passed away this veteran cannot live at home alone our HBPC team joined forces and was able to meet his daily needs until he was able to be admitted into an assisted living facility that next week. This veteran has been having a very difficult time settling into his new home and most recently his dog had to be taken away because he could not care for him in the assisted living facility, we were able to check on him more frequently to make sure all his needs were being met because we are a clinic on wheels and we go into the veterans homes. This veteran is acclimating better to his new home his wounds are almost healed, and I continue to work with him on his nutrition care goals.

We hope that this has helped explain the HBPC program and the purpose of the program within the VA. Stay tuned for more episodes with our HBPC program team. If you have any questions, please contact your nearest VA Medical Center. The VA Medical Center will be able to tell you if they have a HBPC Program in your area and will be able to point you in the right direction if you have questions about the program. Thank you for listening.