Dementia as leading co-morbidity in home bound seniors: A retrospective look at first year of inception of an NP-led medical house call practice Ron Billano Ordona, MSN, FNP Sacramento, CA, USA The Sigma Theta Tau International European Conference Utrecht, The Netherlands June 6-8, 2016

Disclosure Ron Billano Ordona, MSN, FNP is the primary care provider (PCP) at Senior Care Clinic House Calls. The presentation is supported in part by the University of California, Davis Medical Center (UCDMC), Sacramento, CA, USA.

Objectives Acquaint attendees with data collected over a period of one-year for a NP-led medical house call program for homebound seniors. Explore potential for further studies on the subject.

Purpose The purpose of data gathering was to assess trends in the number of cases per identified diagnosis of house calls made by the nurse practitioner in a house calls private practice from its inception in the year 2014.

Literature Review A curious 21st century phenomenon: physicians (and nurse practitioners) reviving the house call (Marsh AG, Caring (CARING), 2005 Aug; 24 (8): 12-6, 18-22, 24). Washington Hospital Center's Medical House Call Program has been offering elderly residents of the poorest area of the D.C., medical treatment in their own homes. (Kroll, NP, University of Texas at Tyler, 2012; Ph.D. v, 86)

Literature Review Stress burden older adults >65: hospitalization 48% inpatient hospitalization days Delirium sets in Dementia worsens (Ahmed & Pearce, 2010)

Literature Review Negative impact of hospitalization to the elderly include functional decline, delirium, polypharmacy, and patient/provider satisfaction of care (Ahmed & Pearce, 2010; Mramor, Hagman, Ford, Oman, & Cumbler, 2015) 

Literature Review In October 2012, the Center for Medicare and Medicaid Services (CMS) began reducing Medicare payments for Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions (CMS.gov, n.d.; MedPAC, 2007).

Literature Review Medical House Calls ER visits reduced by 30% Admissions reduced by 10% In most cases, the medical care is more effective less costly more accessible for both the family and the health care system. (Is there a doctor in the house? De Jonge E; Taler G, Caring (CARING), 2002 Aug; 21 (8): 26-9). (Bader, Patricia, Brandman University, 2014; D.N.P. (85 p)

Method simple analysis of cases a total of nine months in 2014 data obtained using the electronic health record (EHR) used by the practice. 20 patients at the start of the practice in February 2014 to 226 patients by end of November 2014 (a 90% increase over a period of 9 months).

*Not actual patients

Graphics from cartoonstock.com Method Most common diagnoses: Dementia Hypertension Diabetes Hyperlipidemia Kidney disease (Counties of Sacramento and Placer in Northern California). Graphics from cartoonstock.com

Distribution of cases seen in 2014 Results Distribution of cases seen in 2014

Conclusion Suggest further studies. Dementia with presenting co-morbidities: great challenge for medical/ nursing management. Challenges to caregivers. House calls by a medical provider: opportunities to address the challenges, medication management, symptom management, and others.

Conclusion Study limitation One year of a nurse practitioner practice. Practice area studied. We cannot make generalized statements about physician's or nurse practitioner’s practice patterns.

Implications for Practice The United States is currently faced with the challenge of how and where to care for its aging population. Nurse practitioner (NP) home-based care is a potential solution to meet this challenge. Current research indicates that care provision by advanced practice nurses reduces cost, decreases length of stay and readmission to hospitals, and improves patient quality of life. Advanced practice nurses are able to fill the provider gap for aged patients. (Kroll, NP, University of Texas at Tyler, 2012; Ph.D. v, 86).

Implications for Practice There is a resurgence of medical house call services by a combination of physicians and emerging practices by nurse practitioners. House calls by a Nurse Practitioner (NP) opens up opportunities to address some of the challenges that dementia and co-morbidities present. Further exploration at how this practice model can lessen ER visits or hospital readmissions is recommended.

“The exam room is your living room.” -Senior Care Clinic House Calls