Enhancing the Care of Frail Older Adults With Complex Needs Through Home Visits

In this bird's eye view, a female doctor sits on a living room couch with a senior female patient. She holds a clipboard as the patient gestures and speaks. There is a doctor's bag and medical equipment on the coffee table.As a primary care physician at Brigham and Women’s Hospital, Laura N. Frain, MD, MPH, saw firsthand the challenges of caring for older adults, particularly those living with frailty, cognitive impairment/dementia and multiple geriatric syndromes within the primary care system. Now, as a geriatrician in the Brigham’s Division of Aging, she leads collaborations with primary care to develop and implement new models for co-managing outpatient geriatric patients.

In these co-management models, patients continue to receive care from their long-standing PCP and primary care team and, at the same time, benefit from having additional geriatric expertise and potentially ongoing geriatric support, when needed. Unlike traditional consultative models, the geriatric team is fully integrated within the primary care team and provides an extra layer of geriatric support and education for patients, their families, their care partners and their primary care providers and team members.

One example is the Division of Aging’s Targeted Geriatric Home Visit Program. Coordinated by Dr. Frain and Kristin Cardin, NP, the program serves frail older adults with complex medical and social needs in Boston and nearby communities.

“During my clinical research training, I studied the many wonderful geriatric and behavioral health models of care that exist or have been evaluated for older adults in the United States and internationally,” Dr. Frain explained. “We’ve looked closely at what other programs have done and tried to develop a program that works for patients in our particular environment, hospital and many different primary care medical homes.”

Dr. Frain works out of the Phyllis Jen Center and the Brigham’s Advanced Primary Care Associates at South Huntington practice, assisting the primary care teams in caring for geriatric patients with common age-related concerns. However, many frail older patients with complex health issues find it very difficult to travel to a clinic for their care, especially when it involves seeing someone other than their PCP. Yet, both they and their primary care team would like additional geriatric input and support. Dr. Frain and Cardin developed the Targeted Geriatric Home Visit Program to address this reality.

“We quickly realized we needed to extend our geriatric presence from the clinic into the patient’s home,” Dr. Frain said. “We see our patients in their homes to provide longitudinal care around issues such as dementia, caregiver support and education, frailty and mobility issues, falls, safety and medication management.”

Through the Home Visit Program, Cardin, a geriatric nurse practitioner with a background in medical and surgical nursing as well as occupational therapy, visits with older adults in the comfort and privacy of their own home. Her visits include a review of each aspect of the comprehensive geriatric assessment, a detailed safety assessment of the home environment and surroundings, an accurate assessment of the patient’s medications and a combined cognitive and functional assessment.

In most instances, Cardin also meets with a patient’s family members, friends and/or care partners, who provide collateral history and further insight. Most importantly, in the home setting, she can spend more time with the patient, allowing for a more open discussion around the patient’s most pressing questions and concerns as well as exploring his or her hopes, fears and overall goals of care.

Following the home visit, Cardin shares the valuable information she has learned with the primary care team and assists with formulating and implementing a plan of care that addresses the needs identified during the home visit.

“The home visit is unique and very special,” Cardin said. “I have a first-hand opportunity to see what my patient’s day-to-day routine is really like. It allows me a closer look, helping me identify challenges or barriers that may exist; this can only happen if you go into the home. The visit also allows me to see what supports are in place and what medications our patients are actually taking and when. It is an honor to provide my care ‘in real life and in real time,’ something that is very difficult to do in the clinic setting.”

One area of emphasis for Dr. Frain and Cardin in 2018 was building out capacity for e-consults. “Anyone on the primary care team can request an e-consult, and we can help provide some initial geriatric input and help determine if a home visit or an office visit would be more helpful given the circumstances,” Dr. Frain said. “We can then also make official recommendations for everyone else on the care team to follow.”

As for the future, Dr. Frain plans on expanding the program’s geographical reach and integrating a geriatric team into more primary care clinics. Following the success of the program and its enthusiastic reception from patients, their families and the initial primary care teams, the Brigham has announced support for its expansion.

“I am thrilled that more patients and their care teams will have access to this geriatric co-management model, which is designed to ‘flex in and flex out’ when and where needed, over time, to help higher-risk patients achieve what matters most to them and provide high-quality geriatric care,” she concluded.

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