Thursday, January 28, 2016
Home Care for Seniors: a Win-Win
Home Field Advantage
With today's portable medical technology, physicians who make home visits can do as much or more for patients than primary care clinicians in offices, says Dr. Alan Kronhaus, co-founder and CEO of Doctors Making Housecalls, based in Durham, North Carolina.
His practice uses medical labs that can deploy a phlebotomist to a patient's home to draw blood and send the results electronically to the patient's chart. Imaging technicians can do ultrasounds or X-rays in the comfort of the patient's home.
These aren't everyday patients who get home visits. "For the most part, we're seeing frail, elderly, complex patients with multiple, chronic, active problems and often some degree of cognitive impairment," Kronhaus says.
Many clinical advantages come from seeing patients in their own environment, Kronhaus says, like the ability to manage medications more effectively when the doctor can see exactly what's inside the medicine cabinet. It's also a chance to spot nutritional supplements that patients wouldn't have thought to mention during an office visit.
And it's an opportunity to address diet concerns, Kronhaus adds. "You can look into the refrigerator and see how it's stocked – if you've got a diabetic patient who has banana cream pie." Doctors evaluate the environment as well, he says. "We look for things like steep steps without carpeting, area rugs without nonskid padding underneath, electrical cords that could represent a tripping hazard, poor lighting."
To compensate for the "opportunity costs" of the doctor's transit time, patients pay a direct travel fee of $95 per visit. But, Kronhaus says, other costs are avoided, such as paid time off at work taken by family members to escort patients to the doctor's office, the round-trip cost of a wheelchair-enabled van or, in the worst-case scenario, the cost of transport by ambulance.
Doctors Making Housecalls is participating in Independence at Home, a Medicare shared-savings demonstration project involving a handful of home-based primary health providers throughout the country. The project has been "an unabashed success," Kronhaus says. "We've achieved dramatic savings and very significant improvements in quality of care and patient satisfaction."
Piecing It Together
Home health agencies fill a gaping need, but with economic and reimbursement pressures, many are struggling to survive, says Jane Kelly, executive director of the Kansas Home Care Association, a nonprofit trade organization. "There are four agencies out in western Kansas that are trying to serve literally hundreds and hundreds of miles of rural farmlands," she says. "And people can't get services because the agencies can't stay afloat."
With home health care, insurance coverage is often a hurdle. Patients who are not housebound may not be covered, even though getting to medical appointments can be physically challenging and transportation difficult to arrange. There's a high bar for reimbursement, and once a patient shows some improvement, he or she may no longer qualify for home visits. Yet access to skilled nursing, physical therapy and other services at home can prevent costly hospital readmissions and help patients avoid expensive long-term facilities, Kelly says. "Most people want to stay at home as long as they can," she says.
Family members do their best to support ailing parents by assembling a patchwork of skilled and personal services – such as help with toileting, bathing and dressing – through limited insurance coverage and government funding, or by paying out of pocket. "The options are, you piece it together," Kelly says.
On the Road
There's a lot of "windshield time" for nurses providing home care in isolated rural areas, says Terri Wahle, a registered nurse and director of home care at Geary Community Hospital in Junction City, Kansas. Wahle's team works with retired farmers and many other patients with often limited means.
For the nurses, Wahle says, a 10-hour workday may include three hours spent on the road, meaning less time to provide much-needed care for chronic conditions such as diabetes, heart failure and chronic obstructive pulmonary disease. Some homebound patients have several conditions.
After a hospital stay, supports at home may be lacking, Wahle says, even though patients' discharge plans say otherwise. "Do they have a bathroom they can get into with the walker?" she asks. "Are they able to fix themselves a meal? Are they able to get any food at all? Are they taking their medications?" These are some of the signs home health nurses look for.
Without regular access to home health care, some elderly or disabled patients can soon find themselves back in the hospital. "One of the things I've taken pride in for the last 30 years in home care is that we try to keep people in their own home for as long as it's safe and it's possible," Wahle says.
Quality Time at Home
When doctors or nurse practitioners go to patients' homes to make a thorough geriatric assessment, as part of a Medicare home-visit program, everybody wins, according to a recent study. The system saves money from lower hospital admission rates, and patients are less likely to enter long-term care facilities. With referrals to community providers and health plan resources, these patients tend to receive more follow-up care in the community and have a better chance of aging in place.
One problem with traditional health care, in which patients are only seen on providers' turf, is that health issues are dealt with in isolation, says study author Dr. Soeren Mattke, a senior scientist at RAND Corporation, a nonprofit research organization.
"When they go to the physician, they have maybe 10 minutes' face time," Mattke says. "So what often happens is the conversation focuses on what is the most pressing issue that day. But many other things that also have to be handled really never get any attention." Lingering problems from multiple conditions, while not immediately threatening, can worsen and accumulate, he says.
Comprehensive home assessments help uncover clues to frail seniors' health, Mattke says. Nutritional issues can emerge, for instance, like patients subsisting solely on canned beans. Like others, he remarks on the quantities of expired or discontinued medications patients typically have at home.
"After a while, they really don't know what's what anymore," he says. Invariably, he says, it's the most essential medications that patients stop taking first.
Safe Respite and Handy Help
Adult day programs provide respite for family home caregivers so they can return to their responsibilities with energy and spirits restored. "Ninety percent of the people who call us, [it's because] they don't want to put their husband or wife or their mom or their dad in a nursing home or a long-term care facility," says Darlene Turner, director of the West Valley life enrichment program at Benevilla, a provider of adult social care and support services based in Surprise, Arizona.
The situation might be that the husband has dementia and the wife needs a short break. "She would maybe like to go do groceries without having to worry about him, or maybe go get her hair done," Turner says. "Or go have lunch with her friends."
For seniors who attend, these programs improve quality of life, Turner says: "Once they get here, everyone is given an opportunity to have an enriching day, to do things they wouldn't usually do if they were left alone at home." The daily fee for an independent senior is $75, and it's $80 for an individual who requires some staff assistance, Turner says.
Other services, like home-delivered meals, benefit older adults living alone in the community.
Volunteers with Benevilla provide handyman services when needed: changing lightbulbs, replacing air conditioner filters, fixing leaky faucets. "We're actually able to send volunteers to their homes to bring their groceries, to pick them up and take them to doctors' appointments; maybe pick up prescriptions," Turner says. "And that way, they're able to stay in their own environment."
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Home Care for Seniors: a Win-Win