VA Northwest Health Network
Roseburg Home Based Primary Care
You are a Veteran. You served your country. You have a primary care physician at the VA Roseburg Healthcare System (VARHS) and you are eligible for outpatient care. You have had a change in health and you are realizing you are challenged accessing your care.
This is where the VA presents options that are not always available in the private sector. The program is called Home Based Primary Care (HBPC) and VARHS has offered this service in Eugene for several years with great success.
Initially in Eugene, Veterans who lived within 25 miles of the Eugene Based Outpatient Clinic were eligible for the service. VA has enhanced the program by increasing the mileage range to 50 miles. Recently, VARHS stood up the same program in Roseburg by hiring a team of professionals to provide the same service in and around the Roseburg area.
HBPC is unique in that it necessitates care by a complete interdisciplinary team of professionals within the home. HBPC is different from Medicare Skilled home care in that the Veteran is not necessarily homebound, but for a variety of potential reasons such as impaired mobility due to functional limitations or an inability to cope with the clinic environment may deem them eligible for the program. Once a Veterans Primary Care professional refers them to the HBPC team, an evaluation will take place and eligibility will be determined.
Once a Veteran has entered into the program, they are involved in a complete patient centered care design set which involves complete continuity of care. The team consists of a program director, a medical director, a nurse practitioner, an RN case manager, a social worker, a dietitian, a physical therapist, a psychologist and a pharmacist.
The team spends their days in the field. They travel to the home of the Veteran and depending on the health situation of the patient they provide the appropriate care. One example might be that the patient may be in need of a change in medication. The pharmacist on the team will see the patient and review his/her medications and work directly with the team. Decisions are made based on their assessments paying close attention to what the patient wants to do. Any Veteran involved in the program has agreed to accept HBPC as their VA primary care provider, so a relationship is developed between the patient and the team members. Each member of the team has a rapport with the patient and the focus is on a whole-health patient centered care experience for the Veteran.
The nurses schedule their own appointments and coordinate their daily patient visits. They even do lab draws so the patient does not have to leave his/her home. They chart their patients’ care and the team members all have access to medical information. Each week, or more often as needed, the team gets together and discusses the needs of each of their patients, creating a link and knowledge of each patient’s situation and circumstances.
With the great care and success of the HBPC in Eugene, the VA leadership recognized the need to increase the program to make it available in Roseburg. It took some time to hire all the staff and acquire all the equipment to build the program. A design for office space and an area in the hospital was needed for the team and had to be created with the intention of the program growing also carefully considered. At this time, Roseburg has one complete PACT team serving Veterans within the 50 mile radius of the hospital. That means a team member may travel almost as far as the coast, south down the I-5 corridor and all points between the 50 mile radiuses. As the need increases, more staff members will be hired to accommodate the demand. The program was so successful in Eugene, VARHS anticipates a continued growth in the program.
We are excited and pleased to be able to offer this new service in Roseburg to our Veteran patients. There are details in the eligibility process, so the best course of action for Veterans or their care giver is to talk with their current VA primary care provider (PCP). The PCP understands the basic eligibility so they would refer the potential patient to the HBPC team and the team provides the final assessment to determine eligibility.
HBPC provides an opportunity for Veterans to receive the highest quality care with a team of professionals’ right in their home. The team serves Veterans with a continuous provision of routine care and services involving ongoing monitoring, routine comprehensive assessments and coordination of care. This group of health care providers is dedicated to best serve Veterans with complex, chronic, or those with a disabling disease when routine primary care hospital visits are too challenging for the patient.
That is their goal and their commitment. Plain and simple.