Louis A. Johnson VA Medical Center

Home Based Primary Care

The Home Based Primary Care program, also known as HBPC, is proud to be able to provide you with HBPC home care services.  Our HBPC program strives to provide comprehensive medical care and case management to Veterans who require the majority of their primary health care needs accomplished in the home. A multidisciplinary team of health care professionals provides medical and case management services under the direction a Primary Care Provider to assist each Veteran in achieving and maintaining general well health and to develop a better understanding of how to manage and control their chronic diseases.

HBPC Team and Services:

• The Primary Care Provider (PCP) is responsible for the overall management of your care at home.
• The Nurse Case Manager performs routine home health assessments, monitors medications, and provides health education.
• The Social Worker will assist you to obtain VA (Veterans Affairs) benefits, services, and community resources based on your eligibility status.
• The Rehabilitative Therapist assesses your functional abilities, your home environment, and provides adaptive devices and education as needed.
• The Pharmacist will review your medications on a regular basis and make any recommendations to your medical provider.
• The Registered Dietitian will assess your nutritional status, recommend dietary modifications, and provide nutritional education as needed.
• The Psychologist provides psychosocial assessment, treatment, and counseling for you, your family or caregiver as needed.

The HBPC program’s primary goal is to assist our patients in learning how to manage their own health care needs and to remain safe in their own homes. Our dedicated team of highly qualified and experienced nurses, social workers, dieticians, psychologists, occupational therapists, pharmacists and chaplains help patients and families learn to live independently with new or chronic illnesses and adjust to living safely in their homes after returning home from a hospital or a nursing facility admission. Each Veteran who receives Home Based Primary Care (HBPC) maintains their primary care provider.  Our dedicated teams of professionals make home visits and each patient is seen in their own home. The HBPC team closely communicates with the patient’s primary care provider to offer consistent, holistic, and complete health care management.

Admission Criteria

Each of the following factors must be considered in determining whether the Veteran is appropriate for admission to HBPC:

• Veteran is enrolled for VHA care.
• Veteran lives within HBPC's service area of 60 mile drive of the LAJVAMC.
• Veteran has complex chronic disabling disease that necessitates care by an interdisciplinary team.
• Veteran and/or caregiver accept HBPC as the primary care provider.
• Veteran's care needs can be met by HBPC.
• Veteran has an identified caregiver, if the need for one is determined by the HBPC team.
• The Veteran's home is the most appropriate venue for care as determined by the HBPC team.
• The Veteran's home environment is safe for the well-being of the Veteran, the caregiver, and the HBPC team members.

HBPC Team Goals:

• Help you to prevent or reduce the need for hospital admissions and emergency department visits.
• Optimize your health to attain the highest functioning possible within the limits of your illness.
• Maximize your independence.  
• Enhance the quality of your life.
• Coordinate the use of VA and community services to help you to stay in your home as long as possible.
• Assist you and your caregiver to cope with the stress of your chronic illness.
• Recognize and support your individual care needs.
• Enable your home to be a safe and therapeutic environment.

The HBPC team at Louis A. Johnson VA Medical Center strives to provide comprehensive disease education and symptom control for patients with chronic conditions but not limited to such diseases as Diabetes, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease conditions, ALS and other debilitating circumstances that can affect a Veteran’s ability to care for themselves and remain independent in their home. Our staff will make every effort to provide quality individualized health care, education, guidance, and support to each patient and their families.

Please feel free to call or write the HBPC Program Director if there are any questions, concerns, or compliments you or a loved one would like to share or discuss.