An evaluation of home visiting of patients by physicians in geriatric medicine

A Review of Home Visits by Occupational Therapists in a Geriatric Assessment Unit

A review of occupational therapy home visits carried out from a geriatric assessment unit over a 6-month period is reported. There were 179 non-respite admissions of patients previously living at home and 33% of these patients had a pre-discharge occupational therapy home visit. Almost 90% of visits led to discharge home, with the provision of additional aids in 63% and the recommendation of other additional support arrangements in almost 80%. Only one of the 54 patients discharged home was considered to have had a failed discharge.

The practice of geriatrics: specialized geriatric programs and home visits

Home visits have a long history in geriatrics. In this narrative review, the literature on home visits performed by specialists in geriatric medicine (or psychiatry) and/or specialized programs in geriatric medicine (or psychiatry) published between January 1988 and December 2008 was examined. The papers reviewed were few and inconsistent in their message. The lessons that can be derived from them are limited. Draft recommendations about the role of home visiting by specialized geriatric programs in Canada are presented.

Teaching geriatric assessment in home visits: the family physician/geriatrician attachment

BACKGROUND

Geriatric clinical clerkships in Israel teach mostly about the hospitalized elder patient with almost no ambulatory experience. Meanwhile, primary care physicians provide most of the health care to the elderly in the community. This article describes an innovation in the curriculum of the 5th-year family medicine clerkship at the Goldman Medical School of Ben-Gurion University in Israel designed to improve the teaching of geriatrics in the ambulatory setting.

DESCRIPTION

During the clerkship, family physicians perform a home visit to one of their home-ridden elderly patients with a small group of medical students. During this visit, a geriatrician from the local hospital is included to the group for teaching purposes.

EVALUATION

Most students rated this experience positively as did the family physicians and geriatricians who participated in this experience.

CONCLUSIONS

This liaison-attachment teaching experience allows the students to learn aspects of geriatrics that are spared during their geriatric clerkship, allows the family physician to use this opportunity as a consultation for homebound patients, and allows the tertiary care geriatrician to teach in the community.

A survey of domiciliary consultations in medicine for the elderly

The objective of this study was to assess the value of domiciliary consultations carried out by two hospital physicians for care of the elderly, using the resulting admission rates as one of the criteria. The action taken by the physicians on domiciliary visits was also studied. Data were collected retrospectively from all the domiciliary consultations done by the two departmental physicians from January 1992 to December 1992. From totals of 184 and 268 domiciliary consultations only 14.1% and 11.2% of patients seen respectively by consultant 1 and consultant 2 were admitted acutely to hospital. Overall, consultant 1 had something to offer in 92.4% of his domiciliary visits and consultant 2 took action in 81.3% of his domiciliary consultations. Most of the GP practices in the area used the service and only one practice was responsible for more than 10% of one consultant's domiciliary consultations. Domiciliary consultations form a useful service in medicine for the elderly and admission rates to hospital from these visits are low.

Prescribing Strategies for the Frail Elderly: Patient function as an indispensable end point

Current recommendations for prescribing for the frail elderly can be supplemented by others of value to family physicians. Minimization or simplification of medication regimens, proof of medication efficacy, vigilance for adverse drug reactions, and knowledge of aging and medications are important. Compliance is critical for the community-dwelling frail elderly but is rarely a problem in long-term care facilities. High-yield, high-risk conditions with presentations different from the "geriatric giants" must be recognized. Less medication is not necessarily the best treatment. Routine surveillance and frequent follow up are essential to adequate pharmacotherapy of frail elderly people.

Home assessments in geriatrics revisited: an audit of a routine home visiting service

Routine home visiting is a luxury not afforded to other medical specialties. The practice of routine home assessment visiting in geriatric medicine was evaluated in a prospective study of 110 consecutive referrals to determine whether; the response to general practitioners referrals could be predicted from the information given at the time of referral and; to identify where home visiting identified additional information of value in directing services more appropriately. Requests for admission were accurately predicted in 86-96% of cases by the visiting and a control doctor respectively. Additional information of value in directing services and patient management was gained from the home visit in 30% of admissions, 58% of day hospital cases and 80% of outpatients. It is possible to predict the outcome of home visits although implementation of such predictions without direct communication with general practitioners would result in a small number of unnecessary admissions and referrals to day hospital services.

Patient compliance--whose responsibility?

This paper focuses on general practitioner and district nurse knowledge of prescribed drugs taken by their elderly patients, and the evaluation of a method of improving that knowledge by a patient held drug guide. Serious differences were identified in the knowledge of doctors, nurses and patients about drugs. The drug guide was associated with an improvement in patient knowledge of drugs as well as a reduction in disagreements between doctors and nurses. A key issue addressed is patient culpability in compliance. It is argued that this is a simplification which overlooks important factors such as inadequate communication and lack of knowledge on the part of doctors and nurses as well as the difficulties the patient may have with the regime.

Poor vision and the elderly--a domiciliary study

Thirty-four patients living in Norfolk, aged 65 years and over, with visual acuities between 6/60 and counting fingers were interviewed at home to ascertain the degree of their disability and their use of low vision aids. Visual acuity in this range was not associated with patients' mobility or their dependence on others. A threshold of useful vision could not be identified within this range. Use of low vision aids, although disappointing, was more frequent by those who had attended a low vision clinic.

Doctor, nurse and patient knowledge of prescribed medication in primary care

The prescribed medication of elderly patients receiving district nursing care was studied in an inner London group practice. Information on each patient's medication was obtained independently from the patient's doctor, her district nurse and from the patient herself and then compared. This paper focuses on the areas of agreement and disagreement between professionals and patients, and the doctor/nurse meeting as a method of resolving disagreements. The discussion highlights some of the problems of maintaining accurate records in primary care, and the implications for teamwork.

The yield of a home visit in the assessment of geriatric patients

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office-based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5-1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4-3.9). Twenty-three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well-being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in-home assessment contributes unique and meaningful information to the geriatric assessment process.

Geriatric Medicine in the United Kingdom: Lessons to be Learned

Geriatrics in the United Kingdom, through its long history, has created an integrated and co-ordinated system through the development of solid home-care organization centred around the family doctor, and of available and efficient specialized geriatric services based in the geriatric unit. Even if we might not wish to transpose the British system to our country, the lessons to be learned from that system can help to stimulate the debate on the organization of geriatric services in Canada.

Psychiatric assessment of elderly patients in the home: a survey of 176 cases

One hundred and seventy-six homebound elderly patients referred for psychiatric evaluation by family, physician, or community agency were assessed in the home by a geriatrician psychiatrist, accompanied by those involved with the patient's care, whenever possible. Careful attention was paid to the interaction between psychiatric, medical, and social parameters and their collective effect on the aging patient. The most common discrete psychiatric diagnoses were dementia, with or without secondary symptoms; major depression; and paranoid states without dementia. Assessment resulted in home treatment and maintenance through a variety of supportive interventions frequently accompanied by chemotherapy, emergency psychiatric and medical hospitalization, and placement, as well as education of family and community workers.

Alive and well: geriatric medicine in the U.K. in 1984

The function of the hospital geriatric service in the U.K. is described within the context of the overall support for the frail, disabled, and sick elderly in this country. It plays an important part in the secondary care of the very old, and perhaps an even more important part educating the public and the profession to the needs of this rapidly expanding section of the population. A short account is given of the nature of geriatric medicine and the role of the consultant geriatrician. The history, achievements, and current status of the specialty are briefly reviewed, and some of the directions which future developments may take are indicated. Whether or not a comprehensive separate service on the U.K. model emerges in other countries, it is certain that they will need centres of geriatric expertise to pursue research and to provide education and enlightenment for all concerned with the medical problems of old age.

Alcohol and drug use in the elderly visited at home

During a 3 year prospective study, 223 new patients aged 65 and over were seen at their own residences. This setting enabled a detailed record to be made of current medication and alcohol use. The average consumption was 2.9 different drugs daily per patient, but one-third of the patients took 4 or more different preparations. One patient in 10 showed a severe alcohol-related problem. These findings were in a group with an average age of 77, not overtly physically ill, referred for a psychiatric opinion.