by Richard J. Hart Jr., M.D., F.A.C.C.,
Rebecca L. Rush, C.P.A., and
Richard J. Lank
Geriatric Times July/August 2001 Vol. II Issue 4
Some of you may recall the doctor's house call, which vanished from urban areas in the 1950s, but which may still exist in some form in rural areas. House calls became a thing of the past for many reasons. It is too expensive for a physician to visit homebound patients in many locations. The current small doctor-to-patient ratio would spread physicians even more thinly. Patients are living longer, which places additional demand on all physicians. The care a patient receives at the physician's office is more comprehensive than in a home visit. Finally, doctors now rely on alliances with specialists who may practice out of the same clinic.
There is, however, a continuing need for physicians to have unbiased, trained "eyes and ears" to keep them aware of the safety and context of their patients' lives. Patients and their families want to be proactive in maintaining health and independence. There is, therefore, a benefit to having a physician assistance team that provides house calls as part of a practice.
This team provides comprehensive early detection and intervention-decision support to prevent accidents and unplanned drug interactions. The team is also the point of access to qualified providers who enhance, repair or modify a home to improve safety features.
There are many benefits to this team effort. Accidents can be prevented because access to assessments becomes easy, reasonably priced and objective, and barriers to complying with recommendations are minimized. Accreditation of preferred providers will set a high national standard of quality for home assessments and provide peace of mind for long-distance caregivers. Access to the team through the primary care physician will facilitate third-party reimbursement, especially by long-term care insurance companies. Seniors may be more willing to accept the advice of professionals committed to helping them stay independent.
The Physician as Gatekeeper
Independence for patients, as well as caregiver support, can be more accessible by offering services through the primary care physician's office. This model designates the primary care physician as the gatekeeper who provides access to a preferred provider specialist group. The physician can be more involved in the general wellness of the aging patient by delegating to the house-calls team. The house-calls team makes visits with a much broader scope than medical evaluation, including such things as family conflict resolution and completion of recommendations resulting from the home assessment.
Core members of the preferred provider specialist team include an administrator/scheduler, an occupational therapist, a financial steward, a personal emergency response system specialist, an architect familiar with universal design and adaptive environments, and a certified home remodeler. Other members can be recruited.
Home safety visits are not new. However, there are deficiencies and inconsistencies to the way home safety assessments have been completed. Home inspections may have been conducted after the patient has had an accident or by someone wishing to move the patient into a congregate care facility. The assessment may not have taken into account the family or volunteer social system available for supporting independence. The focus may have been limited only to physical surroundings, with little regard to pharmacological causes of trips or falls. There may have been no follow-through to encourage compliance with recommendations. Inspections have only been available either to the very poor (as a social welfare benefit) or the very wealthy. Finally, there were no comparative or follow-up data collected to track completion, compliance or efficacy.
Primary team members will be either licensed professionals or specially trained and certified. This is especially comforting for long-distance caregivers, because an assessment can be conducted at the patient's location, with results that are comparable to those at the caregiver's location, keeping accountability and consistency high.
The 'House' in House Call
Most seniors, according to an AARP questionnaire, want to "age in place" (Bayer and Harper, 2000). However, houses designed for families may be hazardous -- or downright unsafe -- for an aging, frail person. Obstacles to renovations may include the stress of managing the project, finding competent and trustworthy contractors, and identifying financial resources (Steinfeld and Shea, 2001).
As our population ages, there will be a higher percentage of patients over the age of 65, many of whom are accompanied to their doctor appointments by family members. Many patients are parents of adult children who live many miles away or who work full-time and are not reimbursed for helping sustain their parents' independence. Family members need the kind of support and peace of mind that a home safety assessment will provide, and there is additional trust in a team dispatched by their primary care physician. The physician's office needs a local team that is part of a national network and provides competent follow-through services to the physician.
Mitigating the Risk of Falls
Falls are common among the elderly and often lead to loss of independence or even death. According to a Yale University study, the rate of falls among people aged 65 and older is about 30%; among patients aged 80 or older, the rate is 50% (Gill et al., 2000). Of the elderly who do fall, about 10% sustain a serious injury such as a fracture, joint dislocation or severe head injury. Falls and fall-related injuries are also associated with pain, loss of confidence, functional decline and placement in a nursing home.
A home and personal safety evaluation may uncover many high-risk conditions. The team may learn about near-misses and remove hazards. Some risks are easily remedied, but others may require major home modifications. In some cases, a patient may be safer living in another environment.
Many conditions affect an older person's safety. Gill and colleagues (2000) concluded that there are more important features of home and personal safety inspections than simply checking for hand railings and throw rugs to prevent trips and falls. These include increasing muscle strength, improving gait and balance, teaching proper use of assistive devices, wearing correct footwear, and monitoring medications.
Drug Safety Review
The U.S. Surgeon General's Healthy People 2010 program recommends a comprehensive drug utilization screening process by physicians. The screening will highlight unfavorable combinations, especially those that may increase the potential for light-headedness, thermal sensitivity or insomnia. By regularly monitoring for polypharmacy, we can minimize the possibility of harmful drug combinations or combinations that alter the effectiveness of other drugs.
Of the top prescribed medications in 2000, several are at high risk for unwanted interactions. The combination of acetaminophen and codeine (Tylenol 3) has a central nervous system depressant effect when combined with alcohol or the benzodiazepines diazepam (Valium) and lorazepam (Ativan). In addition, herbal medicines should not be taken with this acetaminophen and codeine combination medication. The use of narcotic pain medications and any sedating or mind-altering substances in the elderly has to be weighed very carefully because of the potential for serious accidents, falls and confusion. Selective serotonin reuptake inhibitors should not be used with herbal supplements claiming to include St. John's wort. In its pure form, St. John's wort has substrates that could change the activity of the pharmaceutical drug.
Also impacting the efficacy of medications is diet. Knowledge about an individual's diet will be gathered during the house call. Our team has an herbalist cross-check the safety of various herbal and pharmaceutical combinations.
Successful drug utilization, especially with multiple drugs, requires close monitoring by patients, families, physicians, pharmacists and nurses.
The Occupational Therapist
On house calls, occupational therapists (OTs) are the primary evaluators because they are uniquely qualified to serve as the eyes and ears of the physician. Their field of study includes evaluating people in the context of their surroundings; classifying deficiencies such as vision impairment, hearing loss and other sensory deficits; and recommending alternatives to improve quality of life. In many states, the allied health care professional is certified to act in this capacity only under the orders of a physician. Therefore, in our model the dispatch of an OT through the physician's office ensures legal compliance and improves the possibility of medical insurance reimbursement.
The OT can view the patient's everyday activities and determine present limitations or compensating resources and what assistive devices, footwear or balancing aids may make a person safer and more vital. The OT will also be responsible for conducting the pre-assessment drug utilization review and will be on alert for medications and foods that may cause unwanted drug interactions.
Following assessment, the OT will offer recommendations to improve the odds for safe independence. Depending upon the results, there may be no interventions needed; some repairs or major home modifications may be necessary; or the OT may report that the person may be incapable of living independently. In this event, the OT will contact the family and/or the local social services agency.
Anyone who has a chronic medical condition or lives alone should consider a personal emergency response system (PERS). This system can save lives in the case of an accident or other medical crisis.
The evaluation will also include the frequency with which a person leaves their home. For an active senior, a home-based PERS may be reassuring, but it is useless when they are away from home. There are now a variety of mobile PERS technology products available to summon help if a patient is away from home and stranded, ill or injured.
The Qualified Contractor
Repair companies and construction or remodeling contractors often have a bad reputation. While most repair contractors may be honest, there is no core competency testing or standard pricing, and some contractors have defrauded consumers.
Seniors may be particularly vulnerable to unscrupulous contractors. A person might not make the necessary house repairs because they cannot afford it or cannot do it themselves (Bayer and Harper, 2000). They may also have no one else to do it for them. Steinfeld and Shea (2001) reported that obstacles to recommended repairs or remodeling may include the stress of managing the project and denial that the modification was needed.
Our remodeling team member was a leader in the National Home Remodelers' Association and now develops standard guides by service territory: a short list of capable providers and a rating of their qualifications, price ranges, insurance coverage, reputation and special skills.
Declining functional ability and limitations posed by disability may result in a need for a wheelchair or other adaptive devices. Wider doorways; a ramp; or cut-away counters, sinks and dining tables might be recommended. But who will do this?
Whenever a recommendation requires structural remodeling, the architect team member, who has credentials in universal design, confers with the patient and/or the family. Universal design means that all spaces and products are designed or retrofitted so that anyone can use them without being stigmatized as disabled. This may enhance the resale value of a home where obvious changes for a disabled person are not often considered valuable by the general public. Recommendations might include lighting enhancements, cable-view intercom entry systems and sensors to alert people with hearing impairments.
In apartments or homes where it is impossible or impractical to incorporate these principles, the architect will offer functional, but perhaps more subtle, modifications. Cost of modifications can range from modest to staggering.
The Financial Steward
The financial steward, a certified public accountant in our model, helps the family with a cost/benefit analysis, project management services, medical bill management and routine independent activities of daily living, like balancing checkbooks and paying bills.
A financial steward can help a family raise the necessary funds for a major home modification by helping them identify and classify their own resources (for instance, home equity that can be accessed through reverse or second mortgages, life insurance cash value). The financial steward can also help with construction loans, repair or modification contractor selection, and project expediting.
The Return of the House Call
Physicians are not alone in their concern for the safety and quality of life of elderly patients. The home and personal safety team shares this concern and has a plan of action. When these multidisciplinary professionals work together with the doctor, the patient, the working caregivers, family members, and even health or long-term care insurers all benefit. This is a win-win solution to preventing the pain, suffering, unnecessary or premature institutionalization, or untimely death of our senior citizens -- our neighbors, our friends and our relatives.
Dr. Hart is in private practice in Falls Church, Va.
Ms. Rush is a certified public accountant with Trillium Wellness Programs, LLC and Personal Financial Stewardship Services in Kensington, Md.
Mr. Lank is president of National Eldercare Services Company in Kensington, Md.
(Additional members of our team are: Jane Rohde, I.I.D.A., A.I.A., principal, JSR Associates, Ellicott City, Md.; Amy Scherer, president, Senior Safety Communications Inc., Nashville, Tenn.; Marty Azola, P.E., Azola & Associates, Baltimore.)
Bayer A-H, Harper L (2000), Fixing to Stay: A National Survey on Housing and Home Modification Issues. Executive Summary. Washington, D.C.: AARP.
Gill TM, Williams CS, Tinetti ME (2000), Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Med Care 38(12):1174-1183.
Steinfeld E, Shea SM (2001), Enabling home environments: strategies for aging in place. Buffalo, N.Y.: Center for Inclusive Design & Environmental Access. Available at: www.ap.buffalo.edu/~idea/publications/free_pubs/pubsehes.html. Accessed May 25.