My Scope of Practice: Making House Calls wherever the Patient Calls Home

    Caring for patients along the geriatric continuum, Scott Bolhack, MD, CMD, FACP, conceptualized a vision of care management. In his mind’s eye, he sees medical practice as a painting, a work in progress where he helps fill in the gaps.

Some physicians here, a nurse practitioner there, a social worker, a registered nurse, a wound care specialist. This is no random sowing of healthcare providers, however. Through planning, steady growth, and the employ of experienced professionals, Dr. Bolhack’s Tucson Long-Term Care Medical Group has earned a presence in 19 of the 21 nursing homes in the Tucson, Ariz. metropolitan area, providing care to more than 110 adult care homes and more than 200 subacute patients to whom he is devoted because they “appreciate you showing up.”

    At different points in his career, Dr. Bolhack’s interests have spanned internal medicine, pediatrics, and nutrition in both clinical practice and academia. The East Coast native eventually found his niche in long-term care when he moved to Tucson, went into private practice in long-term care, and discovered he enjoyed interacting with geriatric patients. He was named Director of his first nursing home in 1995, which soon became two Directorships of two subacute units and eventually grew to 11 Medical Directorships because people requested that he come to more and more facilities. “We are growing TLC Medical Consulting Group practice deliberately into a quality improvement organization,” says Dr. Bolhack. “We offer services that include consulting, quality assurance, meeting oversight, generating spreadsheets for documentation and records, and conducting research and presenting posters — one of which received an award from the American Medical Directors Association. The winning poster was titled, ‘Utilizing AMDA Clinical Practice Guidelines: Three CPGs Selected for Development of Implementation Packets’.”

    Patients in his practice in subacute care facilities are seen a minimum of three or four times a week and provided what Dr. Bolhack calls “intense care.” He believes that these post-acute patients require careful attention not met by the minimal regulatory standards. Patients in long-term care/adult care or who are homebound are seen once a month or more as the situation allows. The facilities range from small adult-care homes to high-end assisted-living facilities. Dr. Bolhack is a stickler for the transfer of complete patient records between and among facilities to ensure a seamless flow of information and to avoid gaps in care.

    Most of Dr. Bolhack’s visiting provider staff are nurse practitioners (NPs) who, says Dr. Bolhack, “add so much to what we do as physicians, do so much for the patient, and love what they do.” He notes, “There will be a quarter of a million NPs and physician assistants (PAs) in the US in the near future. I think in 10 to 20 years, most primary care will be delivered by NPs and PAs.” Because he respects the capabilities of NPs and PAs, his staff are afforded choices as to where in the system they want to work (for example, long-term care). The providers in the group can work in a variety of settings including subacute care, long-term care, assisted living, adult care homes, home health and hospital-based palliative care. Dr. Bolhack believes that a result of this employment approach is the practice’s low turnover. “It is a unique model,” he says.

    As the practice has expanded the palliative care piece, partners have been added. Physicians, too, go out to private homes to provide care, as is the case for a homebound patient on a respirator. Several RNs (one with 25 years’ experience in long-term care) and an LPN are among staff who help monitor and educate patients (and caregivers) to foster best practice.

    Generally consistency and quality oriented (although the federal mandate is for quarterly quality assurance assessments, his are performed monthly), Dr. Bolhack wants to create care systems that are fully integrated and follow patients through all of the different settings. “I would like to computerize as soon as possible,” Dr. Bolhack says. “But input is a huge job with a huge amount of cost. Some sort of Tablet PC software with drop-down menus that address groups of patients and coding would be ideal — anything to better integrate hospitals and long-term care electronically. The challenge is not simply an electronic chart, but rather mobility with a computer from multiple providers.”

    Dr. Bolhack also would like to see the geriatric medication nightmare resolved — perhaps a more streamlined scenario where full-time geriatric pharmacies deliver medications to assisted-living facilities. “Patients in assisted living have 29 prescription card choices,” says Dr. Bolhack. “Care facilities and pharmacies need to create a partnership to eliminate errors and billing fiascos.”

    Some of Dr. Bolhack’s ideas will need time to come to fruition; one current pursuit is reaping more immediate rewards. He has recruited Karen Kennedy-Evans, RN, CS, FNP, to establish a wound care program that will increase the expertise of clinicians working in nursing homes and home health. “We have been providing wound care, such as addressing pressure ulcer prevention and management — the exception being plastic surgery and flaps. I want to expand our palliative care piece into the wound care arena, eventually associating with a hyperbaric center of excellence.”

    Dr. Bolhack lectures locally on wound care issues and performs a great deal of the wound care in his practice. “I like to do debridement,” he says. “I had been sending it out but I learned to do it myself.” He also familiarized himself with products. He helped create tracking sheets for wound care provided in long-term care facilities and has been monitoring wounds and providing instruction to staff on how to stage and manage wounds. With Karen’s help, he hopes to create a “true local long-term care/home health wound care program.” To do that, he says, he “needs to find a medical group to work with, perhaps to become an adjunct to delivering wound care in home health.” He feels that physicians rely too heavily on one product — they need to be educated, perhaps via a wound care team, on how to stage and to incorporate other products and protocols into their practices. The educational component of his practice would address these issues. Incredibly, only one facility in Tucson has a dedicated wound care team.

    Consistency across the care continuum is a much-desired goal for the growing elderly population who call nursing staff “family” and nursing facilities “home.” Such consistency should be a mandate. Dr. Bolhack and staff have turned the concept into reality in many aspects of care, now including wound management. “There are frustrations and challenges every step of the way,” Dr. Bolhack says. “But there are also overwhelming rewards in my scope of practice.” 

My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ