Homebound Patients Research Articles

A Palliative Care Career

AFTER TURNING AWAY from a long-imagined career as an English teacher, I entered the family business (medicine). Medical school and residency were both engaging and plagued with considerable uncertainty about where I was heading and how I fit in with the profession. It was also punctuated by a year as a hippie. I was attracted to international health and social medicine, but particularly enjoyed settings such as ambulatory care and psychiatry, where a personal understanding of patients’ lives was valued. Finishing my internal medicine training in 1975, which included a part-time fellowship in psychosomatic medicine, I took a position at Massachusetts General Hospital (MGH). My new job allowed me to continue my interest in the doctor–patient relationship, working with an outstanding role model, John Stoeckle. In addition, I was able to practice primary care medicine in one of the hospital’s neighborhood health clinics in a poor underserved community. Almost by chance, on my first day at this first job, I took over responsibility for two homebound patients, and did my first house calls. I was fascinated by the devotion of the family members: one was a frail, elderly woman who was caring for her demented and sometime violent husband; the other a middle-age bachelor son who had many siblings but was alone caring for his demented mother. I was able to help these caregivers continue their labor, mostly through my simple presence (plus a few technical skills). I also was amazed at how my appreciation of their work and my reassurance that they were doing the right thing for their loved ones helped them better endure and carry on in a very difficult and stressful situation. Another physician–mentor, Roger Sweet, piqued my interest in the skill set required to manage a death at home, and thus launched my career in hospice and palliative care. A small but steadily growing cohort of patients who died at home fostered my clinical expertise in end-of-life care, provided an intellectual challenge and also opportunity for me to become an institutional leader

The Effects of TeleWound Management on Use of Service and Financial Outcomes

This study investigated the effects of a TeleWound program on the use of service and financial outcomes among homebound patients with chronic wounds. The TeleWound program consisted of a Web-based transmission of digital photographs together with a clinical protocol. It enabled homebound patients with chronic pressure ulcers to be monitored remotely by a plastic surgeon. Chronic wounds are highly prevalent among chronically ill patients in the United States (U.S.). About 5 million chronically ill patients in the U.S. have chronic wounds, and the aggregate cost of their care exceeds $20 billion annually. Although 25% of home care referrals in the U.S. are for wounds, less than 0.2% of the registered nurses in the U.S. are wound care certified. This implies that the majority of patients with chronic wounds may not be receiving optimal care in their home environments. We hypothesized that TeleWound management would reduce visits to the emergency department (ED), hospitalization, length of stay, and visit acuity. Hence, it would improve financial performance for the hospital. A quasi-experimental design was used. A sample of 19 patients receiving this intervention was observed prospectively for 2 years. This was matched to a historical control group of an additional 19 patients from hospital records. Findings from the study revealed that TeleWound patients had fewer ED visits, fewer hospitalizations, and shorter length of stay, as compared to the control group. Overall, they encumbered lower cost. The results of this clinical study are striking and provide strong encouragement that a single provider can affect positive clinical and financial outcomes using a telemedicine wound care program. TeleWound was found to be a credible modality to manage pressure ulcers at lower cost and possibly better health outcomes. The next step in this process is to integrate the model into daily practice at bellwether medical centers to determine programmatic effectiveness in larger clinical arenas.

Vergleich der Versorgungsqualität älterer Diabetiker durch ambulante Pflegedienste im häuslichen Bereich mit der im stationären Bereich in Pflegeheimen in Dresden

Due to changes in the age structure of the population the number of frail elderly diabetics is rising. This change is accompanied by an increase in nursing care efforts and requirements in both home care services and nursing homes. The aim of this study was to evaluate the quality of care in the home care and nursing home setting concerning the structure, the process and the outcome quality at the institutional and patient level. This is an observational transversal study. At the institutional level a standardised questionnaire of the German Diabetes Research Institute was sent to all nursing homes (37) and home care services (88) in Dresden. At the patient level 37 homebound patients and 46 residents were recruited. A Geriatric assessment and a clinical examination were performed and a blood sample was analysed. Patients with moderate or severe cognitive impairment were excluded. The prevalence of diabetes in home care services was 27.2% and in nursing homes 36.1%. The participation rate among the institutions was 21.6% (n = 27). In 14% (n = 12) of the diabetic patients the HbA1c was above 8% (poor metabolic control) and in 24% (20) it was between 7% and 8% (regular metabolic control). 56.6% (n = 21) of the homebound elderly diabetics and 46.7% (n = 21) of the nursing home residents with diabetes were hospitalized at least once during the last 12 months. Our study showed a high prevalence of diabetes in both types of institutions in Dresden and a high hospitalisation rate of the elderly diabetics, although 62% of the patients had an optimum metabolic control. These facts indicate that the quality of care of frail elderly diabetics concerning the multimorbidity might be further improved.

A Curriculum to Teach Internal Medicine Residents to Perform House Calls for Older Adults

Physician house calls are an important but underused mode of delivering health care to a growing population of homebound elderly patients. One major barrier to internal medicine physicians making house calls is a lack of training in this setting. This article describes a needs assessment survey of residents from nine internal medicine residency programs for a house call curriculum that combines a longitudinal clinical experience with Internet-based learning. Implementation of the curriculum was begun in July 2006, and data will be collected and results evaluated for at least 2 years. Several educational outcomes from the intervention are anticipated, including increased learner knowledge of house call medicine, improved learner confidence in making house calls, and program director satisfaction with the curriculum. This early work lays the foundation for determining the effect of a carefully designed curriculum on the number of practicing internists with the skills, knowledge, and attitudes necessary to meet the growing need for physician house calls.

Effects of a one-year nursing intervention on depression and anxiety in family caregivers of homebound patients with dementia

目的 评价护理干预对减轻居家痴呆患者照顾者抑郁、焦虑情绪的效果,为居家痴呆患者及其照顾者的社区护理干预提供依据.方法 将临床诊断的53例居家痴呆患者的照顾者随机分为对照组和干预组,分别于干预前和干预后3个月、6个月、9个月、12个月,使用抑郁、焦虑自评量表评定并比较两组照顾者的抑郁、焦虑情绪.结果 实施护理干预后,干预组发生抑郁情绪的照顾者由干预前的10(55.6%)例降低至干预1年后的4(22.2%)例(P＜0.05);干预组发生焦虑情绪的照顾者由干预前的7(38.9%)例降低至干预后1年的2(11.1%)例,但统计学差异不显著.干预组照顾者SDS分值由干预前的(40.22±6.07)分减轻至干预后3月的(33.94±8.58)分(P＜0.05)、干预后6月(34.83±9.16)分(P＜0.05)、干预后9月的(35.89±8.22)分(P＜0.05)及干预后1年的(35.67±6.91)分(P＜0.05);SAS分值由干预前的(35.83±7.69)分减轻至干预后3月的(30.50±8.23)分(P＜0.05)、干预后6月的(33.28±8.71)分,干预后9月的(27.89±5.23)分(P＜0.05)及干预后1年的(29.67±6.18)分(P＜0.05);对照组照顾者的SDS、SAS得分干预前后差异无显著性.结论 针对居家痴呆患者照顾者的护理干预有助于缓解照顾者的抑郁及焦虑情绪。

Telephone follow‐up for patients with amyotrophic lateral sclerosis

The relentless evolution of amyotrophic lateral sclerosis (ALS), a severe neurodegenerative disorder of the upper and lower motoneurons, leads to an increasing level of disability. Most patients, during the course of the disease, become unable to attend the tertiary clinical care center and are thus prevented from enrolling in clinical trials or benefiting from specialized care and management. The main objective of this study was to verify whether the ALS functional rating scale (ALSFRS) could be reliably administered by telephone to patients, when unable to attend the ALS clinic, or to their caregivers. ALSFRS is a validated instrument that assesses the functional status and the disease progression in ALS. We first administered the functional rating scale directly in the clinic to 30 patients, with definite or probable ALS, and to their respective caregivers, and found a very high agreement between the two groups for the total score and the majority of the rating items. Next, we showed, in both patients and caregivers, a high degree of correlation between the total score of the ALSFRS measured by telephone and that reported in the clinic. This indicates that ALSFRS is a reliable instrument for monitoring the disease progression in homebound patients, even when the person contacted by telephone is the caregiver. We also performed a telephone clinic, based on an unstructured interview, with 16 ALS patients at an advanced stage of the disease and unable to attend the ALS clinic. On some occasions, the person interviewed was the caregiver. The symptoms most frequently reported were a worsening of muscle strength, swallowing and breathing problems, constipation, and inability to clear lung secretions. Several patients asked for assistive and adaptive equipment. All patients and caregivers found the telephone clinic very useful and considered it a good complement to the management and care programme.

Occupational Therapy in the Home for Nonhomebound Patients

Home health services are most typically associated with care provided posthospitalization for homebound patients. Occupational therapists are often part of the posthospitalization home care team to provide training in activities of daily living. The home environment is often the more authentic location to continue to provide training in these skills even when the homebound criterion is no longer met. There are other conditions that warrant skilled occupational therapy in the home even when there has not been a hospitalization. Increased awareness of the benefit of occupational therapy in the home, along with available reimbursement options, will hopefully improve knowledge for appropriate referrals. The future holds a need for more occupational therapists to choose to work in home care.

A Multidisciplinary Program for Delivering Primary Care to the Underserved Urban Homebound: Looking Back, Moving Forward

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

A New Way of Viewing Homebound Patients

A New Way of Viewing Homebound Patients

Ethical Issues in Mobile Psychiatric Treatment with Homebound Elderly Patients: The Psychogeriatric Assessment and Treatment in City Housing Experience

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care. Ethical challenges with homebound elderly patients are unique because of patient characteristics as well as features of the treatment environment.

Medication Utilization in an Urban Homebound Population

The number of medically homebound adults has grown with the aging of the U.S. population, yet little is known about their health care utilization. We sought to characterize the health status and medication utilization of an urban cohort of homebound adults and to identify factors associated with medication use in this population. We performed a retrospective cross-sectional analysis of 415 patients enrolled in a primary care program for homebound adults in New York City during October 2002. Numbers of medications were obtained from formularies corroborated by home visits. For patients without prescription insurance, medication out-of-pocket costs were estimated according to average wholesale pricing. Sociodemographic and disease characteristics were obtained by chart abstraction. The median age was 83 years (range 25-106 years). Seventy-seven percent of patients were female, 63% were non-white, and 28% spoke Spanish. Sixty-four percent of patients had Medicaid. The cohort had a mean of 8.2 (range 1-27, standard deviation 4.5) medications prescribed per month. Multivariate analysis showed that increasing age was associated with fewer medications (p <.001). Charlson comorbidity score was positively associated with number of medications (p <.001), whereas Activities of Daily Living score, a measure of functional dependence, was not. Twenty-seven percent of the cohort lacked prescription drug coverage. The total number of medications per month among the uninsured patients was 7.4 (standard deviation 4.4). Estimated median monthly out-of-pocket cost for the uninsured patients was dollar 223 (range dollar 1-dollar 1512). For homebound patients without prescription drug coverage, medication use may represent substantial financial burden. Additional research is needed to determine whether out-of-pocket medication costs represent a barrier to care in this population.

Characteristics of Institutionalized or Homebound Patients Requesting for Visiting Dental Care in Nagasaki and Decision System for Introduction

Characteristics of Institutionalized or Homebound Patients Requesting for Visiting Dental Care in Nagasaki and Decision System for Introduction

Providing homebound patients with pharmaceutical services

Homebound patients with chronic illnesses take more prescription drugs than most people, but unless they have the resources to pay for home pharmaceutical care services, they may not be receiving appropriate counseling about the medicines they take. LifeCare Alliance, an Ohio nonprofit health and

Effectiveness of Home-based Occupational Therapy for Early Discharged Patients with Stroke

Objective To verify the effectiveness of home-based occupational therapy for safe discharge of in-patients with recent stroke. Methods A pre/post interventional design was performed to document patients' outcome during 3 months following discharge. Interventions included improving functioning, reducing environmental risks and the risk associated with early discharge of homebound stroke patients, improving caregivers' handling skills through training, and providing on-site skills training for indoor and outdoor environments. Results Comparing pre- and post-interventional status, a sample of 144 patients showed improvements ( p Conclusion Reduction of environmental risks by on-site consultation, aids to support daily activities, and training in community living can improve functional performance of stroke patients. Furthermore, strengthening caregiver efficacy and patient self-efficacy can result in long-lasting benefit for patients' quality of life.

Telemonitors reduce emergent care visits for homebound congestive heart failure patients

Telemonitors reduce emergent care visits for homebound congestive heart failure patients

A Physician House Call Program for the Homebound

A growing number of homebound frail older adults have multiple chronic diseases with frequent flare ups of acute episodes. A physician house call program affiliated with a nonprofit community health system was deployed as a strategy to improve quality of care for homebound patients. A medical team (either a physician and a medical assistant or a nurse practitioner), with a vehicle filled with portable medical equipment and supplies, fulfills the house call and primary care physician functions, establishes diagnoses, designs a treatment plan, arranges for any other needed services, and fosters continuity of medical care. Interviews and focus groups with selected patients, family caregivers, program staff, and other service providers indicated that the program operated consistently with its intent. For example, the patient and caregiver interviews converged on four major themes: (1) the program improves patients' medication and health management and optimizes health, (2) caregivers felt more informed about the patients' medical conditions and medications and relieved of the burden of transporting patients to physicians, (3) the program reduces use of hospital and emergency services, and (4) the programs enables patients to die at home. The success of any future programs and further replications will depend on creating trusting relationships with local service providers and getting decision makers of affiliated community health systems or hospitals to embrace the necessary vision.

Patterns of complementary therapy use by homebound cancer patients in Taiwan

This study explores the use of complementary therapy and factors associated with the use of such therapies by cancer patients in Taiwan who were receiving surgery, chemotherapy, or radiotherapy and lived at home. Data were collected by purposive sampling and analyzed by chi-square testing. Subjects ( N = 137) from two Taipei area hospital-based oncology centers were interviewed by using a structured questionnaire. Sixty percent of the total sample used complementary therapies. Variables, such as gender, duration of illness, diagnostic stages, chemotherapy, and symptoms distress, were significantly ( p < .05) related to the use of complementary therapies. Western health professionals need to know what complementary therapies their clients are using so that they can respond appropriately to questions raised by their clients, as well as help them to acknowledge diverse kinds of treatment in their therapeutic plans.

Ambulatory photographic screening for diabetic retinopathy in nursing homes.

To evaluate the feasibility and cost of screening for diabetic eye disease in homebound nursing home residents not attending a systematic screening programme. Postal survey identification of residents with diabetes in all nursing homes in Liverpool. An ophthalmologist and nurse performed Bailey-Lovie logmar visual acuity (VA), portable slit-lamp examination, fundus photography, and subjective assessment of ability to cooperate with treatment in a sample of homes. Modified Wisconsin photographic grading was performed. Screen-positive patients were invited to a dedicated assessment clinic. Sight-threatening diabetic eye disease (STED) was defined as any of: moderate preproliferative retinopathy or worse, circinate maculopathy, or exudate within 1 disc diameter of fixation. A total of 54 (78%) nursing homes responded reporting 199/2427 (8.2%) residents with diabetes. Of these, 64/80 (80%) residents in 17 homes were examined: VA possible in 50 (78%); slit-lamp examination in 56 (88%); gradable photographs in at least one eye in 34 (53%); STED in 12 (35%) patients. In all, 35 (70%) patients had Snellen-equivalent VA worse than 6/12 in the better eye, of whom 13 (26%) were worse than 6/60. Of 29 screen positive patients, 12 attended the assessment clinic: one was unable to cooperate outside the home; 11 continue under ophthalmic review, four for previously undetected STED of which one listed for laser photocoagulation. Total cost pound 16,980; cost per screen event pound 60.30. Systematic eye screening in homebound patients with diabetes detects disease but follow-up and treatment is only feasible in a small proportion and at high cost. Alternative targeted assessment is recommended.

Reducing medication confusion in homebound patients: when the data do not conform to the initial hypothesis.

Visiting nurses often find it difficult to reconcile multiple and conflicting medication orders, particularly when more than one physician orders medications. As the authors report, resolving medication order confusion was thought to be very time-consuming--until a team started to collect data.

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.