Intensity of Care and Level of Service: A Reflection of Special Needs in the Aging Community in the South Bronx

Intro Medicare beneficiaries account for a major segment of the nation's total health care cost yet so few have their total health care needs met. Study Observational Methods Use of the Logic Model for Home Based Primary Care (HBPC) Program Development. Pre/Post ANOVA on paired matches to evaluate impact of intervention on cost utilization. Results In year one 189 vulnerable elders were identified as eligible for HBPC mostly from the inpatient setting. All were at 60% risk of further functional decline and death at 12 months. One third perceived their health as either poor or fair and 50% did not have a PCP. Through a CGA 45% were diagnosed with advanced dementia, 31% with moderate dementia and 15% with mild dementia. Only 21% carried a previous diagnosis of dementia. Fourty-six percent scored 5 or higher of the Geriatric Depression Scale. Intensity of care was most pronounced during the first 6-12 weeks of enrollment where health disparities affecting health care were identified and addressed after which patients entered a healthcare maintenance status which required a quarterly visit by a health care provider and a monthly phone call by a CHW. Pre/Post ANOVA on 25 paired matches of patients w/ baseline ER/INPT utilization data 2 or > showed significant decline in both ER and INPT utilization data (p<0.001). Conclusion HBPC providing evidenced-based geriatric assessments and timely care coordination with CHWs provides a viable solution to mitigate health care disparities and decrease healthcare cost in a selected cohort of community-dwelling.