HOME CARE&

Assessment ofCommunity-Dwelling

ElderlyJames T. Birch, Jr., MD, MSPH

Assistant Clinical ProfessorDepartment of Family Medicine

Landon Center on Aging (in cooperation with Holly Cranston, MD)

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

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

Types of Home Visits Illness

When a patient is too ill/functionally impaired for office visit - for acute or chronic illness

Dying/DeathHospice care, grief support, pronouncement of death, support visits for family members

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.

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.

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

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

Statistics Low frequency of home

visits is due to:1. Deficits in physician

compensation for visits2. Time constraints3. Perceived limitations of

technologic support4. Concerns about risk of litigation5. Lack of physician training and

exposure6. Corporate and individual

attitudinal biases

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

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

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

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

Disadvantages Time intensive Less technological

support Financial issues Provider safety

Equipment Essential1. Stethoscope2. Otoscope/Ophthalmoscope3. Sphygmomanometer4. Tongue depressors5. Non-sterile (or sterile) gloves6. Lubricant7. Stool guaiac cards &developer8. Sterile specimen cups9. Disposable thermometers10. Reflex hammer/tuning fork11. Urine dipsticks12. Prescription pad

Optional1. Glucometer2. Dictaphone3. Laptop computer4. Patient education materials5. Tape measure6. Bandage scissors7. 4x4 gauze and tape8. Disposable suture removal kit9. Sublingual nitroglycerin10. Glucometer11. Portable oximetry unit12. Portable ECG

Equipment Anticipate the need for procedures1. Debridement2. Unna boot application3. Dressing change4. Phlebotomy5. Suture removal

Assessing the Patient Use the “INHOMES” mnemonic to help recall the

areas of focus for the home visitI ImmobilityN NutritionH Home EnvironmentO Other PeopleM MedicationsE ExaminationS Safety, Spiritual health, Services

Assessing the Patient I-IMMOBILITY1. Assess ADLs and iADLs2. Ask for a tour of the home3. Observe gait and ambulation through hallways,

bedroom, and negotiating stairs4. 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

Assessing the Patient N-NUTRITION1. Ask about food preferences.2. Ask for permission to look in the

refrigerator, cupboards, and/or pantry3. 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?

Assessing the Patient H-HOME ENVIRONMENT1. Safe neighborhood2. Proximity to services3. Ambient temperature (are the heating

and air conditioning controls accessible and easy to read?)

4. Utilities: running water and temperature

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

Assessing the Patient O-OTHER PEOPLE1. Social support system: family members,

neighbors, friends2. Emergency help3. Identification of person who will serve as

surrogate for the patient (DPOA, living will)

4. Assessment of caregiver stress/burnout

Assessing the Patient M-MEDICATION1. 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 medications4. Consider potential for drug-drug or drug-food interactions5. Assess patient compliance6. Recognize the potential or presence of abuse of OTC

preparations and herbal remedies (i.e. diphenhydramine)

Assessing the Patient E-Examination1. Focused examination based on patient’s needs2. Vital signs3. Cardiopulmonary & neurologic exam4. Skin/wound assessment5. Mobility/Immobility assessment6. Cognitive assessment (MMSE, GDS, SPMSQ)7. Blood glucose monitoring (pt should demonstrate

proper technique)

Assessing the Patient S-SPIRITUAL HEALTH / SERVICES / SAFETY1. 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.

Safety issues1. Utilities: running water and

temperature; hot water temperature <49oC (120oF)

2. Cluttered hallways, desks, and countertops (barriers to the use of canes, walkers, or wheelchairs?)

3. Lighting (stairs, hallways, etc.)

Safety issues1. Seat elevator in bathroom2. Tables, chairs, and other furniture (sturdy

and well-balanced?)3. Locks on doors and windows; ease of

escape in case of fire or other emergency4. Ask : “What number do you dial in case of

emergency?”

Safety issues1. Electrical cords and appliances2. Flooring, throw rugs, non-slip surfaces in

tub/shower, and bathroom floor3. Smoke detectors, fire extinguishers

(batteries?)4. Burners on stove easily left on?5. Pets6. Handrails in bathroom and on stairs

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!

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

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

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

Visit the following websites to check your skills

www.riskdom.com www.environmentalgeriatrics.org

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