Theresa Soriano

Falls in the community-dwelling older adult: a review for primary-care providers.

Falls in the elderly are an important independent marker of frailty. Up to half of elderly people over 65 experience a fall every year. They are associated with high morbidity and mortality and are responsible for greater than 20 billion dollars a year in healthcare costs in the United States. This article presents a review and guide for the primary care provider of the predisposing and situational risk factors for falls; comprehensive assessment for screening and tailored intervention; and discussion of single and multicomponent measures for fall prevention and management in the older person living in the community. Interventions for the cognitively impaired and demented elderly will also be addressed.

To the Hospital and Back Home Again: A Nurse Practitioner‐Based Transitional Care Program for Hospitalized Homebound People

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2‐year study describes a nurse practitioner (NP)‐led transitional care program embedded within an existing home‐based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed‐methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case‐mix index, and admission‐related financial costs were compared before and after the intervention using a pre–post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home‐based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP‐led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.

Reduction in Symptoms for Homebound Patients Receiving Home-Based Primary and Palliative Care

BACKGROUND Increasing numbers of patients are living with multiple, chronic medical conditions and functional impairments that leave them homebound. Home-based primary and palliative care (HBPC) programs provide access to health care services for this vulnerable population. Homebound patients have high symptom burden upon program enrollment. Yet little is known as to how individual symptoms are managed at home, especially over longer time periods. OBJECTIVES The purpose of this study was to determine whether high symptom burden decreases following HBPC enrollment. METHODS All patients newly enrolled in an HBPC program who reported at least one symptom on the Edmonton Symptom Assessment Scale (ESAS) were eligible for telephone ESAS follow-up. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow-up care, interdisciplinary care management including social work, and urgent in-home care as necessary. Multivariate linear mixed models with repeated measures were used to assess the impact of HBPC on pain, depression, anxiety, tiredness, and loss of appetite among patients with moderate to severe symptom levels at baseline. RESULTS One hundred forty patients were followed. Patient pain, anxiety, depression, and tiredness significantly decreased following intervention with symptom reductions seen at 3 weeks and maintained at 12 weeks. (p<0.01) Loss of appetite trended toward an overall significant decrease and showed significant reductions at 12 week follow-up. CONCLUSION In a chronically ill population of urban homebound, patient symptoms can be successfully managed in the home. Future work should continue to explore symptom assessment and management over time for the chronically ill homebound.

Symptom Burden in Chronically Ill Homebound Individuals

To document the degree of symptom burden in an urban homebound population.

The Past, Present, and Future of House Calls

This article describes: the origin and evolution of house calls; what is uniquely gained from house calls for both patients and providers; key clinical issues managed at home; evidence that house calls improve outcomes; organization of house call practices; and changes in Medicare reimbursement, technology, and interdisciplinary team care that have influenced the delivery of home-based medical care.

Home-based primary care: a needed primary-care model for vulnerable populations.

Home-based primary care has a long history in American medicine, and its prevalence is again increasing slowly in the United States in response to a changing demographic, societal, and health-policy climate. There are many models of home-based primary care, including private practice, academic, Veterans Affairs-associated, and concierge practices. There is a growing body of literature supporting the effectiveness of the medical house-call model. New healthcare reform initiatives could further impact the number and size of home-based primary-care practices, including the Independence at Home and the Accountable Care Organization demonstration projects.

The Team Approach to Home‐Based Primary Care: Restructuring Care to Meet Individual, Program, and System Needs

Team‐based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician‐led academic home‐based primary care practice was restructured into a team‐based model. With support from an office‐based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team‐based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.

Significant Unmet Oral Health Needs of Homebound Elderly Adults

To assess the oral health status, use of dental care, and dental needs of homebound elderly adults and to determine whether medical diagnoses or demographic factors influenced perceived oral health.

Oral health status and needs of homebound elderly in an urban home-based primary care service.

OBJECTIVES This study assessed the oral health status, dental utilization and dental needs of the homebound elderly (HBE) care patients within the Mount Sinai Visiting Doctor program. METHODS Of the 334 eligible patients, 57% agreed to participate and 95.4% completed the clinical examinations, the Dental Utilization and Needs survey and Geriatric Oral Health Assessment Index conducted in each subjects home by a trained research team. RESULTS Among 75% who were dentate subjects, 40% needed restorative dental care, 45.6% needed dental extractions, and 33% complained of current oral pain. Overall, 92.0% needed some type of dental care and 96% stated that they had not seen a dentist since they became homebound (mean number of years in program = 3.2 ± 2.58). CONCLUSION Findings show the oral health status of these homebound elderly was poor and their quality of life was significantly affected by the lack of basic dental care.

The Mount Sinai (New York) Visiting Doctors Program: meeting the needs of the urban homebound population.

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center’s Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24–hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, local physicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical, nursing, and social work trainees interested in home-based primary care.