Home Care on the Geriatrics Service: A Medical Student’s Perspective

It was mid-afternoon, and I was accompanying my Geriatrics preceptor on a home visit to a 95-year-old man with multiple medical conditions that included congestive heart failure (CHF). Aside from the three of us, the man’s granddaughter--who also lived with him--was there, and his 98-year-old wife was asleep in a bed in the corner. After a number of cardiac examinations and an ongoing debate about whether or not the man needed to be admitted for a CHF exacerbation, the elderly woman in the corner sat up and said, “Something is burning.” To which the daughter laughed and said, “I forgot to take the chicken out of the oven,” as she quickly left for the kitchen. I consider myself a very open-minded person, and in general I give the elderly a lot of respect and credit, but, I will admit, I was surprised that the most alert and responsive person in the room that day was a sleeping 98-year-old.

I attended a large medical school in Boston, well known for community outreach. For example, there is a student-run Outreach Van Project that serves the homeless of East Boston by living up to its motto of meeting people where they are. Similarly, we also have a rotation on the Geriatrics Home Care Service, which also represents the spirit of a physician as mobile caregiver. I had not given much thought to home visits prior to medical school; to me they were reminiscent of old-fashioned medical bags and “country docs.” On the other hand, I liked the idea of seeing patients in their homes—and felt it refreshing that this is one instance where we don’t make them come to us. My fellow classmates initially had mixed reactions to these experiences. In my group, it was too “slow-paced” for the future surgeons, too “remedial” for the future hospitalists, and not relevant enough for the future pediatricians. In addition, it turned out that no one in my group was planning on going into Geriatrics.

However, there were also few of us who saw this experience as invaluable, and so different from seeing a patient forced to come in to the less than comfortable confines of a clinic. It also seemed that by the end of the rotation, most students appreciated how clinically valuable it can be to visit patients in the home. By going to where your patient lives, you can see his or her environment and with that, so many factors affecting your patient’s health, much of it hidden when the patient comes to you.

For example, if the patient has difficulty walking, one can easily check for a guardrail in the bathroom. Some questions to ask include:

•For a patient with impaired vision: Is there a phone in the house with large numbers or Braille?
•Who helps the patient with paperwork (eg, phone, electric bills)?
•Can the patient sort out his or her own medications?
•Who takes care of picking up refills?

These and countless other questions can immediately be addressed during a home visit and would be much harder or impossible to answer in a clinic encounter. Much of this information involves preventive health, which may be the most effective positive intervention in an elderly patient’s life.

The majority of the patients we saw on the Geriatrics Home Service were either living alone, living with a younger family member, or living near a helping friend. The one commonality among these patients was that they did not quite need an assisted living facility or nursing home, but were not mobile enough to keep regular physician outpatient appointments. We saw a great deal of mentally sharp and highly functional patients, as well as some who appeared almost helpless and lived in shockingly poor and unsanitary conditions. One patient insisted on being examined on her front lawn, for fear if anyone was allowed inside her house it would be declared condemned and she would lose it. We also saw a blind man who lived alone and whose house was filthy, infested with cockroaches, and smelled strongly of stale urine.

In both of these instances, it was certain that something had to be done to remove the patients from the home. However, the doctors we worked with also fought tirelessly to try to return their patients home after setting up services to make the houses livable again. These physicians were among the strongest and most dynamic patient advocates I have ever seen—from one who collaborated with a Santeria priest in order to help his blind patient suffering from visual hallucinations, to another trained in acupuncture who successfully used it to treat her patients’ chronic pain. Above all, they seemed to realize that the best interventions they could perform were those that helped patients stay where they wanted to most--at home. Physician home visits may be their strongest ally in this fight.

While it is intuitive that regular physician home visits will improve the health of an elderly individual, this correlation is not easy to study directly. This is due to the considerable variation in home visit practices and heterogeneity of the populations served. However, meta-analyses have demonstrated a significant correlation between home visits and delay in nursing home placement,¹ statistically significant reductions in mortality and admission to a long-term care facility,² preventive effects on mortality for lower-risk and targeted individuals with multiple follow-ups,³ significant benefits with regard to activities of daily living and reductions in long-term nursing home admissions with annual in-home comprehensive geriatric assessments,⁴ and significant reductions in hospital stays for the elderly utilizing home care.⁵ While meta-analyses have drawbacks, these studies do show that there is strong evidence of home care being measurably beneficial. The strength of one program over the other may be in the targeting of the population and the frequency with which caregivers are able to make their visits.

The elderly have many challenges during this time of life, and fighting to maintain autonomy is one that all of us living to an advanced age will face. While there may be a difference of opinion as to how long to maintain living in one’s home, it is safe to say that you will not find an elderly person declaring, “I can’t wait to move into a nursing home!” For adolescents transitioning to adulthood there is often frustration in the delay of winning independence and being taken seriously as an adult. But this frustration also comes with the security that one day they will gain that independence. The elderly, at the other end of the spectrum, realize that once this independence is lost, they will never regain it. No comfort accompanies them. It would seem remarkable that anyone could get through this period of life free from some degree of depression.

While mental illness can contribute to the need for nursing home placement, this “normal” transition itself brings with it a high risk of depression. The prevalence of depression at the time of nursing home admission is high and difficult to treat.⁶ This suggests more evidence that avoiding or delaying this transition is of great value. Dementia is also a primary contributor to the need for nursing home placement.⁷ However, often home care will be superior to nursing homes for patients with dementia, as well. For example, for those with Alzheimer’s dementia, short-term memory is the early deficit, while long-term memory initially remains intact. For these patients, their home environments remain most familiar to them, whereas a nursing home would require the difficulty of learning an entirely new surrounding.⁸ While long-term nursing home admission is a necessity in some cases, anything that can prevent or delay this move will have undeniable mental health benefits for these patients.

With the elderly population continuing to be the fastest growing population in the United States, the fact that the elderly want to stay in their homes, and the mounting evidence that this is likely the best decision for so many of them, the need for home care expansion cannot be stressed enough. One of the best ways to sow the seeds of future growth is to incorporate more home care training at all medical schools. Many schools have worked this into their curriculum in some ways, but there is a tremendous variability from what some do as compared to others. A survey of 123 medical student deans in the United States in 1994 revealed that less than half of medical schools had any training in home care. Among those that did, in only three schools did all students go on six or more home visits during their clinical years.⁹

While I found the program at my medical school to be an extremely unique and valuable experience, our curriculum was not set up for a mandatory minimum number of home visits or days dedicated to home visits. Therefore, some students went through the same Geriatrics rotation with only a handful of home visits. I feel fortunate to have spent most of my rotation visiting patients at home, and I believe this had a lot to do with how positive it was overall for me.

My experience fits in well with a 2002 study of five U.S. medical schools and their home care programs (mine was not included). The study showed that students were likely to have positive attitudes towards home care with a greater number of home visits, and having exposure to a home visit physician preceptor.¹⁰ Looking back, I was neutral about home visits before the rotation because I knew very little about how they were implemented. Afterwards, I came to realize how much of an impact a home care physician can make in a patient’s life. At the very least, all medical schools should incorporate a home care program into the curriculum that brings this realization to all of its students.

While there may not be a magic number of minimum home visit runs or time spent with a preceptor for a successful program, students should all realize that this practice is practical, effective, and not something that should be left only to nurses or other healthcare professionals. With this effort, home care may righteously become standard practice once again rather than just a remnant of the past.

The author reports no relevant financial relationships.