White River Junction
“Many people say, ‘we don’t know how to define it, we know it when we see it,’ ” said Dr. Daniel Stadler, the geriatric team leader at Dartmouth-Hitchcock Medical Center.
Considerations that come into play include age, cognitive abilities, multiple illnesses and social factors such as caregiver support.
If a patient has a medical event, a visiting registered nurse may be assigned to care for them in their home through Medicare.
But what happens when that care has expired?
“Our concern was, these patients are still frail,” Stadler said.
That was part of the motivation that drove Stadler and Shelia Aubin, community programs director at the Visiting Nurse and Hospice for Vermont and New Hampshire to form Aging at Home. The pilot program aims to have a nurse visit frail patients at least once a month to check in to assess their care and concerns.
“Ideally, we’re trying to use the same nurse,” Aubin said. This will help build patient trust, “so when that patient does have any kind of event … they have a trusting provider they can turn to.”
Since its launch in February, the program has enrolled 25 patients, with plans to expand to 150 by the end of winter. Currently the patients live at private residences, meaning their homes or homes of family members.
The plan is to expand to patients at assisted living facilities as part of the pilot.
To qualify, a patient must be served by the community geriatrics team at DHMC and be referred by a care provider from that team.
The nurse will be covering the patient regardless of the payer source and what stage of care the patient is in. The relationship in that case could span years.
“These are elderly patients who are at risk for some type of event at home,” Stadler said.
The long-term goal of Aging at Home is to build trust between patients and providers, and guide better ongoing health care decisions.
This is particularly apparent in emergency room visits.
“Sometimes, it’s very clear you should go to the hospital,” Stadler said. “Sometimes, you’re not sure.”
By having a trusted nurse make regular check-ins, those decisions could be easier to make and unnecessary hospitalizations could be avoided.
Patients who are considered frail are among the most ulnerable: it is often more difficult for them to leave their homes without assistance. They are also juggling multiple health conditions, which makes it harder to evaluate their condition.
“Their day-to-day baseline functioning level is often not optimal, so when presented in the emergency room, unnecessary and unwanted interventions may be started,” Aubin said.
“By having the system in place where there is the physician and his team that is evaluating whether this patient needs to go to the emergency room and if they do they can follow up and provide good communication regarding the baseline functioning of this individual.”
There are other factors at play.
“It’s also a population that waits to call for assistance,” Aubin said. Patients may be reluctant to call their regular providers about a concern and wait until a problem becomes worse, thus necessitating an ER trip. But a nurse who knows the patient well could pick up on early signs of trouble before it gets to that point.
Stadler’s team covers its patients after hours and in addition to that, patients enrolled in the program also have access to the VNH’s 24/7 hotline and triage support, which includes home visits if needed.
As with almost all good programs, funding is key. Currently, DHMC and VNH are self-funding Aging at Home and are unclear about the long-term costs. The pilot program, in addition to looking at feasibility, is also looking at whether it leads to lower emergency room and hospitalization rates, which in turn could lead to lower health care costs.
Medicare covers home nurse events after an acute event or other specific instances. An example of this is a patient who would need a urinary catheter or dressing that needs to be changed regularly, Aubin said.
Regular check-ins reassure patients once they’re discharged from Medicare paid home-nurse visits “the carpet hasn’t totally been pulled out from under them,” Aubin said.
As the population of aging folks — particularly in the Twin States and Maine — continues to rise, frailty will rise along with it.
Aging at Home “puts more tools in the toolbox,” Stadler said.
Editor’s note: For more information about the program, contact Stadler at 603-653-9143. Liz Sauchelli can be reached at esauchelli@vnews.com or 603-727-3221.
