Nurse practitioners deliver primary home care

February 15, 2011

Olga Featherstone, 92, and a native of Guyana, lives with her daughter, a retired nurse, in Silver Spring, Md. She loves to cook and embroider. For several years, she attended adult day care, where she looked forward to socializing with others. A stroke six years ago left her virtually housebound. Though she has recovered to the point where she can walk very slowly again, she suffers from chronic pain. Now her daughter is experiencing back trouble of her own, and taking her mother to the doctor's office — once a three-hour ordeal — has become nearly impossible.

Despite her frailty and a record of earlier, frequent hospitalizations, Featherstone remains comfortably, happily and safely at home. That's thanks in large part to the working partnership between her daughter, who functions as her primary caregiver, and a geriatric nurse practitioner who delivers primary medical care to her through Holy Cross Hospital's Nurse Practitioners House Calls Program.

Holy Cross, a member of Trinity Health, is in Silver Spring. Its house calls program, administered through Holy Cross Home Care & Hospice, is staffed by two geriatric nurse practitioners who consult with medical director Dr. Barry Rosenbaum, an internist at Holy Cross Hospital. It serves approximately 220 patients in a 20-mile radius that includes Montgomery and Prince George's counties in the suburban Washington, D.C., area.

Margaret Hadley, executive director of Holy Cross Home Care & Hospice, says the hospital's geriatric house call program is part of its mission to provide care to a vulnerable and underserved population. "Right now, we don't have strong financial incentive to provide this service; our program's reimbursement from Medicare doesn't cover all of its cost," she says.

"There are similar programs around the country, but most are associated with large medical centers or group practices in dense urban areas," says Hadley. "Our smaller size, plus the large area we cover, is pretty unique."

Though the geriatric house calls program predates federal health reform by a decade, it aligns with the law's goals. The Patient Protection and Affordable Care Act encourages providers to find ways to make care more coordinated and patient-centered. Congress wants providers to do more to keep frail seniors in their own homes, instead of in hospitals or institutional settings.

Lately, Featherstone has begun to review her early life; and, at times she experiences hallucinations. Even with a need for greater support now that dementia is an issue, Geriatric Nurse Practitioner Mary Blanken says she is absolutely convinced that Featherstone — and the 100 or so other geriatric patients on her house call caseload — fare far better with such an arrangement than they would if they became nursing home residents.

"I love the idea of taking care of patients on their own terms and in their own homes," says Blanken. "When we visit them, we are able to not only check vital signs and review medications, but also assess their entire environment and assist in making alterations to it if necessary. Since many of them require daily care of some kind, we have the opportunity to build relationships with family members and other caregivers, which benefits patients as well."

The individualized, home-based care provided by Holy Cross geriatric nurse practitioners aligns with another goal of health reform: fewer hospital readmissions for high-risk Medicare beneficiaries with conditions such as advanced diabetes and congestive heart failure, Hadley says.

Fifty percent of referrals come from the hospital, when patients are discharged, says Hadley. Another 15 percent come from skilled nursing facilities. The rest, she says, are referrals either from private physicians or from calls by family members who hear about the program by word of mouth.

The nurse practitioners essentially serve as one-on-one, primary medical providers. They give routine medical care, check prescriptions, coordinate care with specialists, and order procedures like EKGs, blood work and in-home chest X-rays. Says Hadley: "We provide a medical home for our patients and visit them on a regular basis, usually once every two or three months, depending on their needs."

As Medicare begins to reset its payment schedules, levying penalties beginning in 2012 on hospitals for excessive readmissions of Medicare patients within 30 days of discharge, health care systems are looking for ways to ensure better follow-up care after a hospital discharge, and such house calls may provide one avenue.

For nurse practitioners like Blanken, however, the benefits of bringing primary care medical services to the patient's home are human in scale. Patients who want to stay in their homes, and can safely do so with support, maintain personal autonomy and dignity.

"My patients are all in the 80s and 90s, most are frail and many have comorbidities. I usually care for them until they either transition to a long-term care facility or hospice or until they pass away," she says. "I consider it a privilege to help them make the transition from fully living life to a peaceful end of life.

"Because I also get to know the patients' families so well, I can assist them in coming to terms with the realities of life and death," she adds. "Our special relationship allows me to help them have conversations about things like advanced directives, so that their loved ones really do have their end-of-life wishes honored. Of course, those discussions are never easy, but they allow me to make a huge, and gratifying, contribution to the emotional stability of the family."

 

Copyright © 2011 by the Catholic Health Association of the United States
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