Physician-directed long-term home health care for the elderly--a century-long experience

Understanding and Improving the Burden and Unmet Needs of Informal Caregivers of Homebound Patients Enrolled in a Home-Based Primary Care Program

The growing homebound population is heavily reliant on informal caregivers, who are increasingly burdened by their roles. This study describes informal caregivers of the homebound who remain caregivers at a 9-month follow-up and examines the impact of a home-based primary care (HBPC) program on caregiver burden and unmet needs using a prospective design with a pre—post intervention assessment. Informal caregivers of the urban homebound are similar to caregivers of other populations and have a broad range of unmet needs. The intervention described is the regular provision of multidisciplinary HBPC. Hundred fourteen caregivers of newly admitted patients complete a baseline interview. For the 56 caregivers who complete a 9-month follow-up interview, participation in HBPC is associated with a statistically significant decrease in overall caregiver burden. At 9 months, caregivers demonstrate an overall decrease in unmet needs, with a statistically significant decrease across two measured domains. These results suggest that the regular provision of multidisciplinary care in the home can mitigate the deleterious impact of informal caregiving.

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

Needs for physician housecalls--views from health and social service providers

This article examines how the role of a physician housecall program is perceived by health and social service providers that refer their clients to the program in a Midwest suburban community. Focus groups and semi-structured interviews with those providers revealed various housecall service needs of their homebound clients. In particular, the fact that home health agencies were the largest referral source suggests that the housecall program fills the needs that are not met by the current mainstream home health services. Our findings reinforce the argument for the increased physician involvement in home care and physician housecalls.

Acceptability to patients of a home hospital

OBJECTIVE

To examine the acceptability to older patients of receiving care in the home for acute medical conditions that require hospital level care by current standards.

DESIGN

Interviews with patients during hospitalization regarding their views of a hypothetical "home hospital."

PARTICIPANTS

Patients (n = 87) admitted to a community-based academic medical center with a primary diagnosis of pneumonia, congestive heart failure, or chronic obstructive airway disease, their nurses (n = 111), and resident physicians (67).

MEASUREMENTS

A questionnaire was developed to measure several domains of acceptability and expectations for care.

RESULTS

A majority of patients agreed that treatment in a home hospital would be more comfortable compared with treatment in a hospital (78.5%), would be less likely to result in an infection (62.5%), and would not be a burden to their family (71.8%). There was less certainty that medical care at home can be as good as in the hospital (56.9%). Nearly three-quarters (72.3%) of patients would choose home hospital if it were available.

CONCLUSION

Patients may be ready to accept home hospital as an alternative for acute care. The acceptability of home hospital to acutely ill older patients is a critical factor in the development of this alternative for care and has the potential for improving satisfaction with care, reducing complications, hastening return to function, and, possibly, of lowering costs of care.

When the patient cannot come to the doctor: a medical housecalls program

OBJECTIVES

To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients. PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems.

PARTICIPANTS

Patients are eligible for the housecalls program if they live within a 15- minute drive of the center and are unable to leave their home.

PROGRAM EVALUATION

The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient-year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one-quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes.

CONCLUSIONS

A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.

Geriatric care approaches in health maintenance organizations

The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.