Enterprise-Wide Initiative (EWI) - Primary Care
Home Based Primary Care (HBPC)
Background
The Home Based Primary Care (HBPC) Enterprise-Wide Initiative (EWI) began providing health care services to Veterans in their homes in 2013. The program is for Veterans who need in-home, team-based support for ongoing diseases and illnesses that affect their health and daily activities. These Veterans usually have difficulty making and keeping clinic visits because their illnesses are severe, and they are often homebound.
This Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office of Rural Health (ORH) program is also for Veterans who feel isolated or whose caregivers are experiencing stress and burden. HBPC can be used along with other home and community-based services so Veterans receive the level of support they need.
HBPC providers deliver health care to rural Veterans in their homes, bringing care to where Veterans live instead of asking them to travel to clinics or hospitals.
Goals and Objectives
The HBPC program is especially effective at reducing nursing home stays, hospitalizations, and emergency room visits. Veterans in HBPC often have complex, long-term health needs, and the program focuses on improving care coordination and chronic disease management for these Veterans.
Positive health outcomes related to HBPC include decreased use of Community Nursing Homes and Community Living Centers, fewer necessary medications, fewer unnecessary medical procedures, and a reduction in other intensive supports and interventions. HBPC also offers an option when facilities have limited outpatient clinic access, inpatient bed space shortages, or challenges with safely discharging Veterans from the hospital. The program emphasizes Veteran satisfaction and safety as key priorities.
Goals
The main goals of HBPC are to:
- Expand sites to increase access to coordinated health care for rural Veterans.
- Expand sites to support higher quality care for rural Veterans.
- Expand sites to improve satisfaction among the Veterans who receive HBPC services.
These goals align with a broader “quintuple aim,” which focuses on improving the patient experience, population health, reducing costs, supporting care team well-being, and advancing health equity.
Objectives
To reach these goals, HBPC focuses on several key objectives:
- Continue sponsoring at least 10 new and partial HBPC teams in rural areas.
- Add new and partial expansion teams and fully staff new programs within the next two years.
- Increase enrollment of Veterans by 25% of program capacity each year until programs are full.
Methodology
The Veterans served by HBPC are at the highest risk for hospitalization and other serious complications. They require focused care from a team that can carefully manage and monitor their individual needs over time.
The HBPC team includes a primary care provider (physician or advanced practice provider), nurse, social worker, dietitian, rehabilitation therapist (such as a physical therapist, occupational therapist, or kinesio therapist), and psychologist. Together, this team provides comprehensive, coordinated care in the Veteran’s home.
A “consult” for HBPC is started when a provider or another VHA health care team member identifies that a Veteran needs HBPC-level care. After the HBPC team reviews and accepts the consult, they call the Veteran to explain the program and schedule a home visit to begin the admission and assessment process.
All clinical team members complete a home visit and a thorough assessment. They then work together to develop an initial plan of care based on what matters most to the Veteran. Putting the Veteran first—focusing on the Veteran’s goals, values, and preferences—is the top priority for the team.
Impact on Rural Veteran Health
Rural and highly rural areas often have limited access to health care options. Providing care to Veterans in their homes is an effective way to address these gaps. HBPC teams deliver care that is highly personalized and focused on what is important to both the Veteran and their care team.
The HBPC program helps Veterans stay in their homes and maintain their health and mobility. This can improve quality of life and allow Veterans to remain connected to their communities instead of moving into institutional settings such as nursing homes.
Rural health HBPC expansion has made a strong contribution to ongoing access to care for rural Veterans. From fiscal years 2013 to 2016, rural HBPC expansion grew to 34 teams. From 2017 to 2024, rural expansion supported 135 new and partial teams. This growth shows the program’s continued role in supporting rural Veterans across the country.
Key Takeaways
HBPC services provide a unique way to address health care access issues and improve fragmented or poorly coordinated care for Veterans with multiple health conditions. The program is patient-centered and holistic. It focuses on the whole Veteran and helps Veterans remain in their homes and communities.
HBPC is an evidence-based, interdisciplinary home care and case management program designed for the highest-risk, sickest, and most frail Veterans. By bringing a full care team into the home, HBPC provides structured, coordinated support that would be hard to achieve through clinic visits alone.
The HBPC program and the implementation of the EWI across the VA system:
- Improve access to care for the highest-risk, sickest, and most frail Veterans.
- Deliver high-quality performance and strong clinical outcomes.
- Achieve high patient satisfaction, with 86% of Veterans rating the program positively.
- Reduce health care costs, including providing care at a lower cost than nursing home alternatives (about $29,000 per year compared to more than $110,000 per year).
- Decrease hospitalizations overall by 63%.
- Decrease emergency room use by 39%.
- Decrease inpatient days of care by 80%.
- Decrease 30-day hospital readmission rates by 29%.
- Decrease end-of-life hospitalizations by 11%.
HBPC helps rural Veterans stay in their homes, which is less expensive for VA than moving a Veteran into a nursing home. At the same time, it supports better outcomes and higher satisfaction for Veterans and their families.
Download the Printable PDF for Healthcare Providers and Researchers.
References
- Edwards ST, O’Neill A, Niederhausen M, et al. Trajectories of care and outcomes of Veterans receiving home-based primary care. Journal of the American Geriatrics Society. 2024;72(1):80–90.
- Federman AD, Brody A, Ritchie CS, et al. Outcomes of home-based primary care for homebound older adults: randomized clinical trial. Journal of the American Geriatrics Society. 2023;71(2):443–454.
- Montano AR, Augustus GE, Halladay CW, Edwards ST, et al. Association of Home-Based Primary Care Enrollment with Social Determinants of Health for Older Veterans. Rhode Island Medical Journal. 2021; May Issue: 33–38.
- Kramer JB, Creekmur B, Mitchell MN, et al. Expanding Home-Based Primary Care to American Indian Reservations and Other Rural Communities: An Observational Study. Journal of the American Geriatrics Society. 2018;66:818–824.
- Edwards ST, Prentice JC, Simon SR, et al. Home-based primary care and the risk of ambulatory care-sensitive condition hospitalization among older Veterans with diabetes mellitus. JAMA Internal Medicine. 2014;174:1796–1803.
- Edes T, Kinosian B, Vuckovic NH, et al. Better access, quality, and cost for clinically complex Veterans with home-based primary care. Journal of the American Geriatrics Society. 2014;62:1954–1961.
Contact
- Darlene Davis, National HBPC Manager, Home Based Primary Care Program, Tampa VA Medical Center, Tampa, FL. Darlene.Davis7@va.gov
- Funding Acknowledgement: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY-00533.
- Citation: Davis, D. (2024). Home Based Primary Care. Department of Veterans Affairs, Veterans Health Administration. Washington, DC: Office of Rural Health.
Rural Health - Navigation
- Office of Rural Health Home page:
https://www.ruralhealth.va.gov/index.asp - Enterprise-Wide Initiatives (EWI) page:
https://www.ruralhealth.va.gov/Enterprise-Wide-Initiatives-EWI.asp - Veterans Rural Health Resource Centers (VRHRC) page:
https://www.ruralhealth.va.gov/Veterans-Rural-Health-Resource-Center-VRHRC.asp
*Link will take Veterans outside of the Department of Veterans Affairs (VA) website. VA does not endorse and is not responsible for the content of the linked websites. The link will open in a new window for the content of the linked websites.
