VA Home Based Primary Care improves quality of care for Veterans

Veteran Kenneth Tutt, age 79, starts his weekdays with an 8:00 a.m. telephone call to his Home Based Primary Care provider of four years, Nurse Practitioner Rhonda Weinhold. Together they review his weight, blood pressure and sugar levels.

Nurse Practitioner Rhonda Weinhold on a recent Home Based Primary Care visit with Veteran Kenneth Tutt.

Like most HBPC patients, Tutt takes a high number of medications to treat multiple health conditions. Weinhold’s 80 HBPC patients average 14 daily medications. Some more than thirty.

HBPC teams set-up 30-day medication boxes for patients. “Instead of having to take their medicines out of 10 or 15 bottles, we put them in a medication organizer for them,” Weinhold said. “We love doing it, but more and more we noticed our patients were on so many medications. We just stopped and thought, are there medications we could potentially get rid of that actually might be doing more harm or that are not needed?”

VA Geriatric Scholars Program

Weinhold recently participated in the VA Geriatric Scholars Program, a workforce development program to integrate geriatrics into primary care practices. One cornerstone of this training is understanding appropriate and potentially inappropriate prescribing practices for older patients. With this in mind, she developed a local quality improvement project to improve medication management, including reducing the average number of medications taken by patients in her panel.

She teamed up with HBPC team member Jena Willis, Doctor of Pharmacy. They decided to consolidate the pharmacist’s medication de-escalation recommendations into a plain-language addendum to the patient’s shared electronic health record—the digital version of a patient’s medical file. “These are the meds we think could possibly be taken off the patient’s medication list,” Weinhold explained.

“I would go into the home and review it face-to-face,” she said. In-person outreach allowed her to engage patients in the decision-making process. When she asked Veterans how they felt about getting off some medicine, reactions were positive. “It was a terrific idea,” Tutt recalled. “Overall, everyone was completely satisfied. We had no adverse effects or outcomes.”

Innovation

Once Weinhold and Dr. Willis fine-tuned their process, Weinhold brought the registered nurses and the others onboard. It was a team effort. Three registered nurses met in person with 80 patients over six months. “We were able to decrease the number of medications by two medicines per patient on average,” Weinhold said. “That’s huge when you’re taking 15 to 20 medications.”

“It worked like clockwork with the Staunton team,” said Dr. Willis, who will soon introduce the program to all HBPC teams at the Salem VA Medical Center.

“Right when we started this project our pharmacy residents just happened to be working on a grand rounds presentation,” said Dr. Willis. “The grand rounds lecture series was on the de-escalation of therapy for the medical department. When the pharmacy residents sent out their presentation for review, Dr. Willis brought them up-to-speed with what they were already doing in HBPC. The residents added the information to their presentation as an introduction to the rest of the medical facility.”

“Research shows the more medication patients are on, especially for the elderly population, the greater the risk for falls,” Weinhold said.

“The most rewarding thing is providing improved quality of life for our patients, whether it’s three more days, three more years, or thirty more years,” Dr. Willis said.

Maureen Jerrett is a contract writer for VA Geriatric Scholars Program