June 06, 2018

House calls program reduces number of ER visits

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More than 500 patients have been visited by physicians and nurse practitioners in UAB’s House Calls program since 2014.

A nurse takes 74-year-old Jo Smith’s temperature, measures her blood pressure and draws blood while a doctor conducts a checkup and reviews her vitals. All of this takes place while Smith sits at a kitchen table in her daughter’s Gardendale, Alabama, home. While this seems like a routine doctor’s visit, it is a life-changer for Smith and her family.

Smith suffered a stroke in June 2016, leaving her paralyzed on the right side of her body. She could no longer walk, making it nearly impossible for her daughter to take her to doctor’s appointments on her own.

“It’s really difficult to move her in and out of the house,” said Michelle Johnson, Smith’s daughter, who is also a researcher in the Molecular and Cellular Pathology Department at the University of Alabama at Birmingham. “Her wheelchair is heavy, and it is difficult to get it up our portable ramp and into the car. I can barely do it by myself. In fact, I threw out my back trying to move her when she first moved in with us.”

The visit is part of UAB’s House Calls program, a program run out of UAB’s Division of Gerontology, Geriatrics and Palliative Care, through which members of an interdisciplinary team including a physician, nurse practitioner, medical assistant and social worker travel to the homes of patients who cannot travel to their doctor’s office for appointments.

“This has truly been a game-changer,” Johnson said. “My mother can now have her appointments from the comfort of our home. She doesn’t have to wait in a waiting room, we don’t have to transport her, and she gets to be comfortable during the visit.”

house calls 2Each visit allows Grammas, right, and her team to thoroughly evaluate the patient’s health and their daily needs.On a case-by-case basis, geriatric physicians at UAB have sporadically made home visits — mostly to frail older adults — for the past 20 years. In 2014, there were about 25 patients informally managed this way. House Calls director Marianthe Grammas, M.D., assistant professor in the Division of Gerontology, Geriatrics and Palliative Care, says she realized there was a greater need to expand the program when she took over in 2014.

“I would see very frail, vulnerable, older patients who were constantly coming in and out of the hospital,” Grammas said. “Because they were not able to physically get to their doctor’s office, they would end up in the emergency room or the hospital for mostly non-emergency issues.”

Since 2014, the UAB House Calls panel has touched more than 500 patient lives and manages an active weekly census of 250 patients.

Once they increased the number of patients in the program, they saw life-changing results. Over a six-month period, there was a 50 percent reduction in emergency room visits among the patients enrolled in the House Calls program.

“We know that, for these patients, coming to the hospital not only is burdensome, but also increases the risk of functional decline, not to mention it adds to caregiver strain,” said Grammas.

The program has grown to include two nurse practitioners, a social worker, a certified medical assistant and a nurse care coordinator. 

The types of patients they see are primarily older adults who are in their 80s on average, but Grammas says they do see younger patients who have severe chronic conditions or serious injuries that make it difficult to leave the home. They also must live within a 30-mile radius of UAB.

Each visit allows Grammas and her team to thoroughly evaluate the patient’s health and their daily needs and living conditions.

“During the visit, we ask questions about what a typical day is like, who visits, who is available to help, and how they are able to complete their activities of daily living,” Grammas said. “We walk around the house and assess the safety of their living space. If we are concerned about food insecurity, we will ask to look in their cabinets or fridge to see what they’re eating, what food they have, see if the labels are expired, and if they have the things that are nutritious and appropriate for their chronic conditions.”

“Being in the home gives us a lens that we wouldn’t otherwise have if we were just seeing a patient in the clinic. We are able to gain a deeper understanding of how the patient is managing their medical conditions and functional needs in the context of the environment where they live.”

A social worker will often accompany on one of the initial visits to evaluate the safety of the home and to determine what resources would benefit the patient and/or the caregiver(s).

“Being in the home means we can see things and say things like, ‘Let’s pull up that rug, because it could be a trip hazard,’ or ‘There’s not enough lighting in this area, so if you need to come into the room at night, you may trip and fall,’” Grammas said. “It gives us a lens that we wouldn’t otherwise have if we were just seeing a patient in the clinic. We are able to gain a much deeper understanding of how the patient is managing their medical conditions and functional needs in the context of the environment where they live.”

The visits also focus on the patient’s caregivers to find out what support they need to continue to provide for their loved one. In Jo Smith’s case, this has been a relief for her daughter.

“When I mention to people that her doctor comes to the house, they sort of pause and then their mouth falls open, and I say, ‘Yeah, her doctor at UAB comes to my house to care for her,’” Johnson said. “It has removed the burden of making her upset and uncomfortable. It’s also helped keep her out of a nursing home and the hospital.”

Providing care in this setting allows the team to develop a comprehensive care plan that addresses the goals and the needs of the patient and caregivers in a truly person-centered way.

“We are able to intervene with problems hopefully before they escalate to be something very serious that would result in a hospitalization,” Grammas explained. “Because Michelle and her husband work full time, this alleviates her from having to take additional time off work to try to get things she would need to transport her mom to the clinic.”

The individual, personal care from Grammas and her team is not lost on Johnson.

“The House Calls program is invaluable not only for my mother, but also for me,” Johnson said. “I know this program is great, and a big reason is that it also has a great, caring leader.”
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