1. HOME CARE & Assessment o f Community-Dwelling Elderly James T. Birch, Jr., MD, MSPH Assistant Clinical Professor Department of Family Medicine Landon Center on Aging (in cooperation with Holly Cranston, MD)

2. HOME CARE & Assessment of Community Dwelling Elderly Segments of this presentation were modified, with permission, from one originally developed by Deb Mostek, MD for the University of Nebraska Program in Aging under funding from the Donald W. Reynolds and John A. Hartford Foundations

3. Steps to Attaining Objectives Types of Home Visits Indications for Home Visits Home visit statistics Advantages/Disadvantages Equipment Patient Assessment Safety issues

4. Types of Home Visits Illness When a patient is too ill/functionally impaired for office visit - for acute or chronic illness Dying/Death Hospice care, grief support, pronouncement of death, support visits for family members

5. Types of Home Visits Assessment Done for patients who may or may not be receiving home health services. Physical exam, home safety evaluation, patient safety evaluation can be conducted at this type of visit.

6. Types of Home Visits Hospital follow-up May help to prevent “bounce back” to hospital prematurely. Helps to assure that the patient is receiving all of the ordered supplies, services, and adhering to medication schedules.

7. Indications for Home Visits Any condition creating physical impairment or limitation of mobility; Lack of transportation Caregiver burden concern Suspected elder abuse or neglect Polypharmacy or medication compliance issues Failure to thrive Refusal to keep office visit appointments Recent history of falls at home Psychiatric illness or behaviorally difficult Evaluation of need for placement outside of home

8. Statistics Before WWII, 40% of patient-physician encounters occurred in the home 1990: 0.88% (<1%) of Medicare patients receive home visits from physicians 1994: 66/123 medical schools offered home visit specific instruction; only 3/123 required > 5 home visits General practitioners 12% of PCP work force but make 26% of house calls

9. Statistics Low frequency of home visits is due to: 1. Deficits in physician compensation for visits 2. Time constraints 3. Perceived limitations of technologic support 4. Concerns about risk of litigation 5. Lack of physician training and exposure 6. Corporate and individual attitudinal biases

10. Statistics on Home Health Care $22.3 billion dollar industry 44% of patients discharged from the hospital require post- hospital care; either nursing home or home health care 43 referrals/year per physician among internists and family physicians J Am Geriatr Soc 1992;40:1241-9

11. Statistics on Home Health Care 5-10% of patients in a primary care practice receive home health care. National homecare and Hospice Survey 1992 30%+ of patients age 85 or older require at least one home health care visit per year. Medical Management of the Home Care patient: Guidelines for Physicians 1998 by AMA 2% of home care patients received physician home visits. National Homecare and hospice Survey 1992

12. Advantages Improved medical care through the revealing of unknown health care needs Ability to assess the environment which can lead to design and implementation of home-based interventions that prevent falls and other self- injury Insight into psychosocial issues Enhancement of physician-patient relationship

13. Advantages Home-based assessments increase the prospect of elderly patients remaining at home. Cleveland Clinic Journal of Medicine May 2001 Assessments are done in familiar surroundings OT, PT can tailor rehab to a patient’s home Physicians report a higher level of practice satisfaction than those who do not offer this service

14. Disadvantages Time intensive Less technological support Financial issues Provider safety

15. Equipment Essential 1. Stethoscope 2. Otoscope/Ophthalmoscope 3. Sphygmomanometer 4. Tongue depressors 5. Non-sterile (or sterile) gloves 6. Lubricant 7. Stool guaiac cards &developer 8. Sterile specimen cups 9. Disposable thermometers 10. Reflex hammer/tuning fork 11. Urine dipsticks 12. Prescription pad Optional 1. Glucometer 2. Dictaphone 3. Laptop computer 4. Patient education materials 5. Tape measure 6. Bandage scissors 7. 4x4 gauze and tape 8. Disposable suture removal kit 9. Sublingual nitroglycerin 10. Glucometer 11. Portable oximetry unit 12. Portable ECG

16. Equipment Anticipate the need for procedures 1. Debridement 2. Unna boot application 3. Dressing change 4. Phlebotomy 5. Suture removal

17. Assessing the Patient Use the “INHOMES” mnemonic to help recall the areas of focus for the home visit I Immobility N Nutrition HHome Environment OOther People MMedications EExamination SSafety, Spiritual health, Services

18. Assessing the Patient I- IMMOBILITY 1. Assess ADLs and iADLs 2. Ask for a tour of the home 3. Observe gait and ambulation through hallways, bedroom, and negotiating stairs 4. Ask the patient to act out their routines (getting in and out of bed, opening medication bottles, performing personal hygiene) 5. Direct corrective interventions where deficiencies are noted 6. Talk with other members of the household about functional concerns

19. Assessing the Patient N- NUTRITION 1. Ask about food preferences. 2. Ask for permission to look in the refrigerator, cupboards, and/or pantry 3. Ask about food preparation: who prepares it? How often does the patient eat during the day? How is shopping for food accomplished? How is it delivered?

20. Assessing the Patient H- HOME ENVIRONMENT 1. Safe neighborhood 2. Proximity to services 3. Ambient temperature (are the heating and air conditioning controls accessible and easy to read?) 4. Utilities: running water and temperature

21. Remember ! “…cleanliness is a cultural matter that should be ignored, unless lack of it is a diagnostic clue, an aesthetic barrier for the caregivers, or a medical risk.” Cleveland Clinic Journal of Medicine, May 2001

22. Assessing the Patient O- OTHER PEOPLE 1. Social support system: family members, neighbors, friends 2. Emergency help 3. Identification of person who will serve as surrogate for the patient (DPOA, living will) 4. Assessment of caregiver stress/burnout

23. Assessing the Patient M- MEDICATION 1. Gather ALL of the patient’s medications in the home (medicine cabinet, refrigerator, drawers, counters, etc.) 2. Evaluate the type, amount, and frequency of medication use, noting the organization and method of delivery (self- administered or help from family/friends) 3. Review indications for medications 4. Consider potential for drug-drug or drug-food interactions 5. Assess patient compliance 6. Recognize the potential or presence of abuse of OTC preparations and herbal remedies (i.e. diphenhydramine)

24. Assessing the Patient E- Examination 1. Focused examination based on patient’s needs 2. Vital signs 3. Cardiopulmonary & neurologic exam 4. Skin/wound assessment 5. Mobility/Immobility assessment 6. Cognitive assessment (MMSE, GDS, SPMSQ) 7. Blood glucose monitoring (pt should demonstrate proper technique)

25. Assessing the Patient S -SPIRITUAL HEALTH / SERVICES / SAFETY 1. Peruse the home for religious objects/reading materials. This could initiate a discussion of spirituality as a healing and coping strategy 2. Coordinating the home visit with home health agencies and having their nurses present can facilitate communication and cooperation between patient, physician, and other agencies. Questions can be answered, orders clarified, priorities and perspectives discussed, etc.

26. Safety issues 1. Utilities: running water and temperature; hot water temperature <49 o C (120 o F) 2. Cluttered hallways, desks, and countertops (barriers to the use of canes, walkers, or wheelchairs?) 3. Lighting (stairs, hallways, etc.)

27. Safety issues 1. Seat elevator in bathroom 2. Tables, chairs, and other furniture (sturdy and well-balanced?) 3. Locks on doors and windows; ease of escape in case of fire or other emergency 4. Ask : “What number do you dial in case of emergency?”

28. Safety issues 1. Electrical cords and appliances 2. Flooring, throw rugs, non-slip surfaces in tub/shower, and bathroom floor 3. Smoke detectors, fire extinguishers (batteries?) 4. Burners on stove easily left on? 5. Pets 6. Handrails in bathroom and on stairs

29. Personal Safety Take a map and your cell phone Contact the patient or caregiver when you are en route for a visit If you’re going to a known high crime area, schedule visits in the A.M., avoid wearing a white coat, use alternative carrying vehicle instead of the “black bag” (i.e fishing tackle box) If you question your safety, KEEP DRIVING!

30. Improving Efficiency Limit geographical area to be covered Plan a half-day of routine home visits (approx. 4 patients) in one general neighborhood Start with the address furthest away and work towards office or home Document the reason for the home visit and history and examination as medically appropriate

31. Summary Is assistance available to compensate for the patient’s functional limitations? Determine goals of treatment and their risks Implement interventions where indicated Address psychosocial issues Be prepared for minor procedures Utilize strategies to improve efficiency Use the home visit checklist http://www.aafp.org/afp/991001ap/1481.html

32. Summary “…house calls are a vital part of medical care, a link to the past, and a unique opportunity for service, commitment, and compassion.” N Engl J Med, Dec 18,1997; 337(25): 1815-20

33. Visit the following websites to check your skills www.riskdom.com www.environmentalgeriatrics.org

34. Additional References Unwin, B.K., Jerant, A.F. The Home Visit. American Family Physician; Vol. 60/No. 5 (October 1, 1999) Meyer, G.S., Gibbons, R.V.; N Engl J Med, Dec 18,1997; 337(25): 1815-20 Swagerty, D.L. House Calls in Primary Care; Kansas Reynolds Program in Aging, Univ. of KS School of Medicine