« The Dual Agenda: November 5, 2014 Issue

Eldercare Voices

An Interview with Denise Brown on the Medical House Calls Program and the Value of Team Care

Denise Brown, MSN, GNP-BC, is a board certified Adult-Gerontological Primary Care Advance Practice Nurse with the University Hospitals Case Medical Center, Department of Family Medicine/Geriatrics, Medical House Calls Program in Cleveland, Ohio. Unlike traditional clinic-based practices, she follows her older adult patients, many of whom are dually eligible for Medicare and Medicaid, through home visits, and team collaboration. The Dual Agenda had the opportunity to interview Denise for this Eldercare Voices perspective.

Thinking in terms of older adults overall, not limited to dually eligible individuals, what would you say is the importance and chief benefit of a home-visit model by a specialized Geriatric Nurse Practitioner?

Denise Brown: I think the importance of home visits for elders is, number one, to provide quality care to some of the most frail and impoverished patients, who otherwise would not get ongoing medical care. In our model, this is done with a sense of compassion and consideration for their advanced age.

What do you see and learn in a home visit that you wouldn’t in a clinical office visit.

DB: Something I hear all the time from my frail older patients is they feel rushed at the doctor’s office, because it takes them longer to perform routine tasks – to travel there, to get into an exam room, to get undressed. Also you can see something called “white coat syndrome.” You put them in a clinical setting and their blood pressure goes up from feeling stressed.

When I make a home visit, I always keep in mind that I am a guest in their home. I try to respect whatever customs and traditions they observe in their home, to help them be at ease. I am able to assess their nutritional and economic status and can see, for example, that someone who is taking their blood pressure medication properly may be undermining that by having a lot of high sodium canned foods in their kitchen. In addition to evaluations, such as nutrition and looking for potential hazards in the home or problems with medication handling, my additional training allows me to recognize atypical presentation of medical conditions, and to pick up small changes over time. I try to identify changes that, with early intervention, can prevent something more serious from developing. For example, new-onset of confusion, could be an early sign of a cardiac problem or an infection.

How important are home visits to preventing hospitalization?

DB: By recognizing early onset of symptoms in a home visit, we can diagnose, treat and hopefully see results that often can prevent hospitalization. This is key, as there are studies out there confirming what we already know from personal experience: which is that most elders prefer to stay in their homes. They don’t want to be institutionalized. They very often are emphatic that they don’t want to go to the hospital. However, when I go into their home, my approach is to let all my patients know that safety is the key. If it’s not a safe situation staying in the home, that is the deal breaker, and then we have to look at other options. But short of that, we do all we can to help keep them in their home safely. Most times, they just need additional support services. With elders, preserving function is key to keeping the option available of staying in their home.

What can you learn about the family support system by visiting in the home?

DB: By following a patient through home visits over time, you become almost like a member of the family, so you get to gauge caregiver stress and caregiver burden. That part is really apparent in the home. When family members come to the doctor’s office, they may hide their stress and fatigue. There is a belief that, “you don’t act like that in front of the doctor.” In the home, I can observe firsthand the stress of a wife who is exhausted after being up all night watching over her husband who has dementia. Identification of issues, whether medical or psycho-social, early on and getting them connected to the proper resources can avoid lots of very difficult situations. It could be referral to the Alzheimer’s Association if an elder needs those services, or connecting to various other types of services.

How do you collaborate with other providers?

DB: I work closely with a collaborating physician, as well as a wonderful team of nurses through area home care agencies. I have relationships with pharmacists in the area, who also know the needs of my patients very well. It is a multidisciplinary collaborative approach and the goal is to do everything you can to keep this patient functional, living independently and safely. So we all rely on each other. 

How often do you make a home visit?

DB: I generally see my patients in their homes once a month. Between visits, they will have more frequent visits from a home care agency nurse, who will report any changes in their condition. The team roles must be clearly defined. For example, a nurse can check blood pressure, but cannot adjust medications. Advanced practice nurses have obtained additional master’s degree-level education to be able to prevent, diagnose and treat illnesses. We try to be efficient in our scheduling, so we don’t overlap visits. In some cases, managing of heart conditions or other advanced chronic conditions are done with the assistance of new technologies.

Can you share some examples of those?

DB: There are a lot of studies about reductions in readmissions of heart failure patients thanks to tracking at home. When they retain excess fluid, gain several pounds from that, and start having symptoms, these patients often go to the ER. Now we can use tele-monitoring to check their weight and blood pressure daily and have that information sent to us over the telephone. A special scale unit in the home automatically plays a recording each day reminding the elder to weigh themselves. The monitoring nurses have guidelines about when weight changes require that they call me so I can adjust the medications. The same works for telephonic pacemaker checks. This has been huge. It has changed my practice significantly. Portable x-rays or EKGs can be done in the home, too. The results are called in to me, and the determination can be made on whether or not a patient should seek an ER evaluation. All these things are so important for frail older folks who have difficulty getting out to a doctor’s office. I think this is the wave of the future.

What do you see as the future of team care?

DB: I’m actually excited about it. When you look at new models of care, I really do see the wave of the future being that we’ll see more advanced nurse practitioners as primary care providers, working in a team with a collaborating physician. Here in Ohio we are losing primary care physicians. In future models of care, I think you’ll see more Nurse Practitioners (NPs) being the main patient contact, collaborating with the team physician, whenever needed. You can have a number of clinics being run by NPs with the collaborating physician overseeing the system.

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