Mount Sinai Visiting Doctors Program Research Articles

Meeting the Challenges of COVID-19: Evaluation of Nurse-Led Changes to Telephonic Assessment.

The early months of the COVID-19 pandemic caused suspension of physician home visits at our NYC home-based primary care practice as well as disruptions in community-based services homebound patients rely on. This produced gaps in care for a vulnerable patient population that is considered underserved and medically and socially complex. Telephone triage nurses at Mount Sinai Visiting Doctors Program responded to these gaps in care with targeted enhancements to telephonic patient assessment: creating an encrypted email address to receive photographs, the use of two Epic dot phrases to screen and educate regarding COVID-19, assessment of patients' ability to complete a video visit, the reassessment of goals of care, and the assessment of changes in home care services. We surveyed 15 attending physicians in our practice to evaluate primary care providers' opinions regarding changes in nurse telephone triage and how helpful they were in managing patients at home during the early pandemic. We found enhancements to nurse telephone triage were viewed by physicians as beneficial, valuable, and improved patient care. Physicians found changes improved timeliness of care, could improve self-management, helped avoid transfer to emergency department, and helped manage patient care at home. As the pandemic continues and telehealth becomes more widely used, nurse telephone triage may be adaptable to help care for a variety of patient populations during future public health emergencies.

Predictors of Place of Death of Individuals in a Home-Based Primary and Palliative Care Program.

To investigate factors associated with place of death of individuals in the Mount Sinai Visiting Doctors Program (MSVD). A retrospective chart review was performed of all MSVD participants who died in 2012 to assess predictors of place of death in the last month of life. MSVD, a home-based primary and palliative care program in New York. MSVD participants who were discharged from the program because of death between January 2012 and December 2012 and died at home, in inpatient hospice, or in the hospital (N = 183). Electronic medical records were reviewed to collect information on demographic characteristics, physician visits, and end-of-life conversations. Of 183 participants, 103 (56%) died at home, approximately twice the national average; 28 (15%) died in inpatient hospice; and 52 (28%) died in the hospital. Bivariate analyses showed that participants who were white, aged 90 and older, non-Medicaid, or had a recorded preference for place of death were more likely to die outside the hospital. Diagnoses and living situation were not significantly associated with place of death. Multivariate logistic regression analysis showed no statistical association between place of death and home visits in the last month of life (odds ratio = 1.21, 95% confidence interval = 0.52-2.77). Home-based primary and palliative care results in a high likelihood of nonhospital death, although certain demographic characteristics are strong predictors of death in the hospital. For MSVD participants, home visits in the last month of life were not associated with death outside the hospital.

Association Between Symptom Burden and Time to Hospitalization, Nursing Home Placement, and Death Among the Chronically Ill Urban Homebound

ContextHomebound adults experience significant symptom burden. ObjectivesTo examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death. MethodsThree hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death. ResultsOf the study sample, 45% had severe symptom burden (i.e., Edmonton Symptom Assessment Scale score >6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P < 0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P < 0.01), higher prevalence of depression (43.4% vs. 12.0%, P < 0.01), lower prevalence of dementia (34.3% vs. 60.6%, P < 0.01), and used fewer hours of home health services (73.6 vs. 94.4 hours/wk, P < 0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio = 1.51, 95% CI 1.06–2.15) in adjusted models but had no association with time to nursing home placement or death. ConclusionThe homebound with severe symptom burden represents a unique cohort of patients who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population.

Home Is Where the Care Is: Bringing Palliative Care Expertise into the Community (FR411)

Meng Zhang, MD, Mount Sinai Visiting Doctors Program, New York, NY Thomas Cornwell, MD, Cadence Health Care System, Wheaton, IL Deanna Bower, DO, Housecall Providers, Portland, OR Brook Calton, MD, University of California, San Francisco, San Francisco, CA Ania Wajnberg, MD, Icahn School of Medicine at Mount Sinai, New York, NY Elizabeth McCormick, MD, Icahn School of Medicine at Mount Sinai, New York, NY

The Critical Role of Social Workers in Home-Based Primary Care

The growing homebound population has many complex biomedical and psychosocial needs and requires a team-based approach to care (Smith, Ornstein, Soriano, Muller, & Boal, 2006). The Mount Sinai Visiting Doctors Program (MSVD), a large interdisciplinary home-based primary care program in New York City, has a vibrant social work program that is integrated into the routine care of homebound patients. We describe the assessment process used by MSVD social workers, highlight examples of successful social work care, and discuss why social workers’ individualized care plans are essential for keeping patients with chronic illness living safely in the community. Despite barriers to widespread implementation, such social work involvement within similar home-based clinical programs is essential in the interdisciplinary care of our most needy patients.

Predictors of Place of Death Among Patients in a Home-Based Primary Care Program (SA510-B)

1.Understand the role of home-based primary care in facilitating place of death.2.Understand the literature regarding predictors of home death. Studies show that although most people would prefer to die at home, at least two-thirds die in an institutional setting. The Mount Sinai Visiting Doctors Program (MSVD), a home-based primary care (HBPC) model, treats more than1,000 homebound patients in Manhattan. There has not yet been an in-depth analysis of care in the last month of life in HBPC and how symptoms, frequency of visits, and demographic characteristics influence place of death. To determine predictors of location of death in HBPC. We performed retrospective chart reviews of all 189 MSVD patients who died in 2012. Six patients (3.17%) died in nursing homes and were excluded because we could not access their care patterns. Of the remaining 183 patients, 52 (28.42%) died in the hospital and 131 (71.58%) died outside the hospital—103 (56.28%) at home and 28 (15.30%) in inpatient hospice. Forty-six (25.14%) were male, 161 (90.45%) had do not resuscitate (DNR) orders, 88 (48.35%) had outpatient hospice, 102 (55.74%) had Medicaid, and 25 (13.81%) lived alone. Non-hospital death was more common for White patients (P<0.001), patients≥90 years of age (P=0.021), those in home hospice (P<0.001), and those with a documented preference not to be hospitalized (P=0.036). There was no statistically significant association between the likelihood of home death and functional status at enrollment; the number of home visits in the last month; presence of a caregiver; living alone; and dementia, cancer, stroke, or heart or lung disease. Our results suggest that HBPC facilitates a frequency of home death far above the national average. Even with the support offered by HBPC, socioeconomic status, ethnicity, and age play a role in predicting place of death. HBPC can help meet patients' wishes regarding place of death, irrespective of comorbidities and whether the patient lives alone, and highlights the importance of addressing this issue with patients and caregivers.

Symptom Management over Time Among Homebound Patients Receiving Home-Based Primary and Palliative Care (SA527-A)

1.Review changes in symptom burden over time among chronically ill homebound.2.Describe management of symptoms among homebound patients receiving home-based primary care services. Increasing numbers of patients, many of whom are frail and elderly, are living with multiple chronic medical conditions and functional impairments that leave them homebound. Home-based primary care (HBPC) programs provide access to healthcare services for this vulnerable population. The Mount Sinai Visiting Doctors Program (MSVD) is a primary and palliative care program that cares for over 1,000 homebound patients annually. Our previous study showed that homebound patients have high symptom burden upon program entry including pain (47%) presumably due to the conditions and/or treatments that contribute to their homebound state. Yet little is known as to how individual symptoms are treated at home and how they respond to intervention, especially over longer time periods. The purpose of this study was to see how symptoms change over time following HBPC enrollment. HBPC patients who reported any symptoms on the Edmonton Symptom Assessment Scale (ESAS) at program entry between 2008 and 2010 were eligible for telephone ESAS follow-up at 3 week and 12 week intervals. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow up care, interdisciplinary care management including social work, and urgent in home care as necessary. Paired t-tests assessed change between baseline and subsequent time points. 130 patients were followed. For each individual symptom, among those with baseline moderate or severe symptoms, mean symptom score decreased at 3 week follow up (p < .05). Patient pain, anxiety, depression, lack of well-being, loss of appetite, drowsiness, nausea, and tiredness remained significantly decreased at 12 week follow-up. In a non-hospice chronically ill population of urban homebound, patient symptoms can be successfully managed in the home.

Nonmedical factors associated with prolonged hospital length of stay in an urban homebound population

Prolonged length of stay (LOS) is a major concern for hospitalized populations at risk for adverse events. Homebound patients are at particular risk for long stays and may have unique discharge needs because of their commitment to be cared for at home despite poor functional status. The goal of this study was to describe factors contributing to long hospitalizations in the homebound population. This retrospective observational pilot study included all 2007 discharges that occurred for patients at The Mount Sinai Hospital enrolled in the Mount Sinai Visiting Doctors Program. Long-stay patients were defined as those having an LOS 2 standard deviations above the mean. Hospitalization days were defined as "nonmedical" when patients medically ready for discharge remained in the hospital. Patients discharged immediately after determination of medical readiness were characterized as "medical stay" cases. The University HealthSystems Consortium Database was used to calculate expected LOS and the LOS ratio. Chart reviews were performed to describe long-stay cases as nonmedical or medical. The average LOS for 479 discharges was 7.84 days, with a mean LOS Ratio of 1.23. Seventeen cases were determined to be long stays. Eight of these cases (47%) were defined as nonmedical stays. These accounted for 136 days of hospitalization and 32% of total long-stay days. The most common reason for a nonmedical stay was nursing facility placement delay. Nonmedical factors accounted for nearly one-third of all long-stay days in the hospitalized homebound population. Increased interdisciplinary collaboration may help address homebound patient LOS.

The Mount Sinai (New York) Visiting Doctors Program: Meeting the Needs of the Urban Homebound Population

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center's Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24-hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, localphysicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical nursing, and social work trainees interested in home-based primary care.

Who Do Global Health Missions Benefit More: Trainees or the Communities They Target?

Jonathan A. Ripp, MD, MPH, is an assistant professor of medicine at the Mount Sinai School of Medicine in New York City, where he sees patients with the Mount Sinai Visiting Doctors program. He is also the associate director of the School of Medicine's Global Health Center, co-chair of the American Society of Tropical Medicine and Hygiene's sub-section on Global Health, and an external reviewer on the selection committee for the Yale/Stanford Johnson & Johnson International Health Scholarship Program.

Seasonal Influenza Vaccination among Homebound Elderly Receiving Home-Based Primary Care in New York City

Seasonal influenza vaccination is recommended for all persons aged ≥50 years to reduce influenza related morbidity and mortality, but vaccination coverage among community-dwelling elderly remains low. Homebound elderly receiving home-based primary care (HBPC) have fewer barriers to vaccination than other community-dwelling elderly. The Mount Sinai Visiting Doctors (MSVD) program provides HBPC to homebound elderly in New York City. This study assessed seasonal influenza vaccination coverage within an urban HBPC program and identified factors associated with vaccine refusal. A cross-sectional analysis of data from the 2008-2009 influenza season was completed and influenza vaccination coverage was assessed. The association between social, demographic and health-related characteristics and vaccine refusal was evaluated using bivariate analysis and multivariable logistic regression. Of 689 people aged >65 eligible for influenza vaccination, 578 (84%) accepted and 111 (16%) refused vaccination. In multivariable analysis, vaccine refusal was positively associated with female gender (adjusted odds ratio [AOR] = 1.85, 95% confidence interval [CI] 1.02, 3.35), black race (AOR = 2.04, 95% CI 1.28, 3.25), and living alone (AOR = 1.71, 95% CI 1.10, 2.67), and negatively associated with dementia (AOR = 0.59, 95% CI 0.37, 0.91). Seasonal influenza vaccine coverage in the MSVD program was high compared to nursing home and community-dwelling elderly. Offering patients vaccination at home without additional expense will likely improve vaccine coverage among urban homebound elderly. Understanding why vaccine refusal rates are higher among females, black patients, and those living alone should guide interventions to increase vaccine acceptance among this population.

Complimentary and Alternative Medicine Use Among Homebound Patients

PURPOSE: Complementary and Alternative Medicine (CAM) can be defined as medical practices not taught widely at US medical schools or generally available at US hospitals. National studies suggest that between 30–40% of the general US population use CAM. These users tend to be more educated, have higher incomes, and are more likely to be between the ages of 30–49. However, to date, no study has documented the use of CAM among the homebound population, patients who are usually elderly, debilitated, and have less access to medical care. We studied the use of alternative therapies in homebound patients of the Mount Sinai Visiting Doctors Program serving the inner city of New York. METHODS: Eligibility for the study was limited to patients who are in the Visiting Doctors Program, and whose mini-mental status exam score was greater than 20 or who were deemed competent to complete the survey by their primary care provider. Participant's CAM use was assessed by a survey administered by an interviewer at the patient's home. RESULTS: Forty-nine consecutive, eligible patients were interviewed and a survey completed. Among the respondents, 84% were women, the mean age was 78.6 (STD = 14.1). Respondents were 51% Caucasian, 27% African-American, 14% Hispanic and 8% other. On rating their own health, 69% rated it as poor to fair, 22% rated it as good, and 8% rated it as very good to excellent. Sixty-nine percent of the respondents reported using one or more CAM in the past 12 months. Commonly used CAM included: vitamins/minerals (33%) [excluding MVI, calcium], spiritual healing (27%), and herbal remedies (20%). Spiritual healing included prayer and faith healing. The most common herbal remedies were garlic, ginger, and chamomile tea. Among CAM users, their main sources of information about CAM came from their own physicians (32%), family/friends/co-workers (18%), and newspaper/radio/TV (18%). CONCLUSION: The use of CAM in this elderly, debilitated, homebound population was significantly higher than that of the general population. It is especially important for physicians who care for homebound patients to be aware of and discuss the use of CAM. Clinicians can then better understand any potential associated health consequences and help their patients make informed decisions about their CAM use.