Reflections of medical students on visiting chronically ill older patients in the home

The expanding number of Americans living with chronic illness necessitates educating future physicians about chronic illness care. Weill Cornell Medical College's Chronic Illness Care in the Home Setting Program (CIC-HSP), a mandatory part of the primary care clerkship, exposes medical students to persons with chronic illness via a half day of house calls with a geriatrics team. The investigators sought to qualitatively assess the effect of the CIC-HSP on medical students and recent medical graduates. Fifty-two prospective participants were approached, and 50 (96%) with varying training levels and time since completing the program were interviewed. Most respondents (63%) found that the home visits taught them important approaches to caring for the chronically ill, such as individualizing care to meet patients' individual needs and improving quality of life as a goal of care. Students remarked that the experience enhanced their empathy (18%) and sensitivity (20%) toward chronically ill patients and increased their appreciation for chronic illness care (35%). Many participants reported that patients were more empowered in the home (55%) and perceived greater rapport and warmth between the doctor and patient (57%) in the home (vs office) setting. The vast majority of recent medical graduates (84%) related that this educational exposure continued to positively influence their approach to patient care. A home visit experience with a geriatrics team can help foster medical students' understanding of the psychosocial and medical aspects of chronic illness, teach relevant approaches to patient care, and improve students' attitudes toward caring for the chronically ill.     

Mi Casa o Su Casa? Assessing Function and Values in the Home

Clinical instruction for medical students traditionally occurs in hospitals and offices, whereas patients and families face many health issues in their homes. This is particularly true for frail older adults, those with chronic illness, and patients at the end of life. The authors sought to incorporate geriatrics, primary care, and palliative care into house calls for medical students by integrating a home visit experience into their ambulatory clerkship. Using a guide jointly developed by geriatrics, primary care, and palliative care faculty, students conduct three home visits with a patient from their community preceptor's practice. The first visit focused on medical diagnoses and symptoms, the second on functional assessment/geriatric syndromes, and the third on social/cultural and end-of-life values. Students completed a 2,000-word write-up, including a narrative using the "voice" of the patient. Students presented the cases in small groups facilitated by geriatric and palliative care faculty. Eighty-three percent of students reported positive feedback about the experience. Based on write-ups and program evaluation, students voiced improved knowledge of functional assessment, geriatric syndromes, and progression of chronic illness. Students also poignantly expressed advantages of home visits in exploring psychosocial aspects of medicine, including affirming the humanity of medicine, understanding family systems, providing patient-centered care, and understanding patient beliefs. Several students expressed pursuing a house calls career. A longitudinal home visit experience for medical students can successfully enhance the geriatric, ambulatory care, and palliative care curricular content of undergraduate education and positively affect student's attitudes toward the chronically ill and homebound.     

Home visits in a rural office practice

Objective:To describe the clinical features of home visits and their role in continuity of care, costs, and benefits in a rural office practice. Design:Prospective study of all home visits performed during a 26-month period. Setting:A general medicine teaching office practice located in rural Virginia. Patients:All persons to whom home visits were made during the study period. Main results:138 home visits were made to 47 patients who had a mean age of 73.2 years. Home visits accounted for 1.4% of patient encounters in the practice, required a mean of 7.1 miles of one-way travel and a mean of 48 minutes, including travel time, to complete, and generated $36 in income per visit. Most patients (27 of 47) were not permanently homebound. Reasons for patients’ being homebound were grouped into six categories (acute illness, frail elderly, terminal illness, advanced chronic disease, neurologic problem, and miscellaneous reasons). The reasons for visits were grouped into four categories (acute self-limited illness, exacerbation of chronic disease, routine follow-up of chronic disease, and psychosocial problem). Physicians judged that 80% of home visits represented appropriate use of their services. In addition, 46% of home visits made an emergency room visit unnecessary, and 9% made a hospital admission unnecessary. At the time of 75% of home visits, physicians reported personal benefits of making the visit. Conclusions:Home visits have an important role in the care of ambulatory as well as permanently homebound patients. While physicians judged most home visits to be appropriate and personally beneficial, these visits required more time and generated less revenue than did office visits for comparable problems. Because home visits generated as well as prevented the use of medical services, their impact on the overall cost of medical care in this setting is unclear. Received from the Division of General Medicine, Department of Medicine, University of Virginia Health Sciences Center, Charlottesville, Virginia.     

The Team Approach to Home‐Based Primary Care: Restructuring Care to Meet Individual,Program, and System Needs

Team‐based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician‐led academic home‐based primary care practice was restructured into a team‐based model. With support from an office‐based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team‐based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.     

Principles of Gerontology for Osteopathic Medical Students

This paper describes the implementation of a course to provide medical students with opportunities to understand the phenomenon of aging and to develop a comprehensive view of the unique needs and problems of the elderly. A team of faculty members representing various academic disciplines related to the study of aging or long-term care lead the students in discussing topics such as the biological, psychological and sociological aspects of aging; functional assessment; health promotion for the elderly; community perspectives in long-term care; and clinical considerations of care to the elderly. A key feature of the course is an assigned visit to an elderly individual at home. Through observing and assessing the elderly in their own home environment, students obtain a more realistic and complete comprehension of the interrelatedness of the many factors that must be considered in caring for the elderly.     

Continuous Quality Improvement Principles Used in an Interdisciplinary,Multisite Geriatrics Clerkship

This article describes how Continuous Quality Improvement (CQI) principles have been used in the development and support of a Geriatric Medicine Clerkshipb for fourth-year medical students. Among these principles, consumer orientation, repeated evaluation of clerkship components, and improvement through a team approach are central to the basic pedagogy of the course. The clerkship has many educational components including lectures, community agency visits, clinical work in a nursing home, interviews with caregivers, home visits and geriatric rehabilitation assessments. CQI principles set the framework for the evaluation and improvement of all these elements. The incorporation of students, faculty and the other teaching professionals into the CQI process facilitates a teamwork understanding of older patient care, and a commitment to the interdisciplinary teaching of geriatric medicine.     

Individual versus team case management in optimizing community care for chronically ill patients with dementia

Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.     

Uncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill

Background: Sub-optimal use of prescribed medication is often associated with unplanned hospitalisation among the chronically ill.
Aims: To examine the extent of sub-optimal use of prescribed medication in a 'high risk' patient cohort recently discharged from acute hospital care.
Methods: Chronically ill patients discharged from acute hospital care ( n =342) were studied. At one week post discharge a home visit was performed by a nurse and a pharmacist during which medication management (including compliance and medication—related knowledge) was assessed.
Results: During the majority of home visits at least one medication-related problem was detected: approximately half of the cohort subject to a 'reliable' pill-count were found to be mal-compliant and almost all demonstrated inadequate medication-related knowledge. Mal-compliance was correlated with ≥ five prescribed medications (Odds ratio [OR] 2.6: p <0.002). Comparatively, lower medication-related knowledge was correlated with age >75 years (OR 2.2: p <0.001), exacerbation of a pre-existing chronic illness (OR 2.7: p =0.044) and six years formal education (OR 1.9: p ≥0.004). Neither were modulated by extent of in-hospital counselling. Other previously unknown problems detected during the home visit included hoarding of previously prescribed medication (35%) and reducing medication intake to minimise costs (21%).
Conclusions: Management of prescribed medications among chronically ill patients recently discharged from acute hospital care is often sub-optimal. Assessment of medication management in the home provides an invaluable opportunity to detect and address problems likely to result in poorer health outcomes.     

Rheumatologists on the road: a subspecialist's role in caring for the homebound

Objective

By 2030, the number of permanently homebound individuals in the US will increase by 50% to reach 2 million. However, no medicine subspecialty consult services exist for this rising subset of the population. This pilot program establishes a rheumatology consult service for the Mount Sinai Visiting Doctors, the largest primary care academic home visit program in the nation serving more than 1,000 patients in New York City. Our service addresses the unmet need for homebound patients with rheumatic diseases, and secondarily provides an educational opportunity for trainees in community‐based rheumatology.

Methods

Using an electronic medical record, home‐based primary care physicians sent consult requests to the Rheumatology Division. Initial assessments were made using the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire.

Results

Over 12 months, 57 home visits were made: 31 new consults and 26 followup visits. Reasons for referral included medical management of a known connective tissue disease, question of inflammatory arthritis, and procedures. The demographics for new consults were as follows: 94% women, 45% Hispanic, and 80% between ages 60 and 101 years. Thirty‐nine percent of patients had rheumatoid arthritis. Treatment interventions included addition of a disease‐modifying antirheumatic drug in 11 patients, 11 procedures, nonpharmacologic management in 8 patients, and a change in the dose of the existing medication in 5 patients. At the initial evaluation, the average RAPID3 scores for patients reflected high severity of disease.

Conclusion

The number of consults and the severity of disease seen highlight the importance of a rheumatologist's role in the community, especially because the number of homebound patients will dramatically increase in the future.     

A Team Disclosure of Error Educational Activity: Objective Outcomes

Medical errors can involve multiple team members. Few curricula are being developed to provide instruction on disclosing medical errors that include simulation training with interprofessional team disclosure. To explore more objective evidence for the value of an educational activity on team disclosure of errors, faculty developed and assessed the effectiveness of a multimodal educational activity for learning team‐based disclosure of a medical error. This study employed a methodological triangulation research design. Participants (N = 458) included students enrolled in academic programs at three separate institutions. The activity allowed students to practice team communication while: (1) discussing a medical error within the team; (2) planning for the disclosure of the error; and (3) conducting the disclosure. Faculty assessed individual student's change in knowledge and, using a rubric, rated the performance of the student teams during a simulation with a standardized family member (SFM). Students had a high level of preexisting knowledge and demonstrated the greatest knowledge gains in questions regarding the approach to disclosure (P < .001) and timing of an apology (P < .001). Both SFMs and individual students rated the team error disclosure behavior highly (rho = 0.54; P < .001). Most participants (more than 80%) felt the activity was worth their time and that they were more comfortable with disclosing a medical error as a result of having completed the activity. This activity for interprofessional simulation of team‐based disclosure of a medical error was effective for teaching students about and how to perform this type of important disclosure.     

Neighborhood health center patients who use minor tranquilizers.

Thirty-four ambulatory medical patients who had used minor tranquilizers for varying lengths of time were interviewed to determine their medical and psychiatric statuses, and to learn their own perspective of their medical care. The population was elderly of lower socioeconomic status, and chronically ill (a significant minority with serious and disabling illness). Depressive equivalents, depression, and anxiety were prominent, but clinical states requiring psychiatric care were not. Slightly less than one-half were alcoholic. Forty-one percent took the medications for target symptoms other than anxiety, and 76% believed these agents were efficacious. Chronic users had significantly more chronic medical illness, and significantly more somatization, anxiety, and fatigue.     

Connecting Social,Clinical, and Home Care Services for Persons with Serious Illness in the Community

The medical, psychological, cognitive, and social needs of older adults with serious illness are best met by coordinated and team‐based services and support. These services are best provided in a seamless care model anchored by integrated biopsychosocial assessments focused on what matters to older adults and their social determinants of health; individualized care plans with shared goals; care provision and management; and quality measurement with continuous improvement. This model requires (1) racially and ethnically diverse healthcare professionals, including mental health and direct service workers, with training in aging and team collaboration; (2) an integrated network of community‐based organizations (CBOs) providing in‐home services; (3) an electronic communication platform that spans the system of providers and organizations with skilled technology staff; and (4) payment models that incentivize team‐based care across the continuum of services, including CBOs, with adequate salaries and academic loan forgiveness to recruit and retain high‐quality team members. Assuring that this model is effective requires ongoing quality assurance measures that include not only quality of care and utilization data to demonstrate cost offsets of service integration, but also quality of life for both the older adults and the family members caring for them. Although this may seem a lofty ideal in comparison with our current fragmented system, we review models that provide the key elements effectively and cost efficiently. We then propose an Essential Care Model that defines best practice in meeting the needs of older adults with serious illness and their families. J Am Geriatr Soc 67:S412–S418, 2019.     

Social Learning: Medical Student Perceptions of Geriatric House Calls

Bandura's social learning theory provides a useful conceptual framework to understand medical students' perceptions of a house calls experience at Virginia Commonwealth University School of Medicine. Social learning and role modeling reflect Liaison Committee on Medical Education guidelines for “Medical schools (to) ensure that the learning environment for medical students promotes the development of explicit and appropriate professional attributes (attitudes, behaviors, and identity) in their medical students.” This qualitative study reports findings from open-ended survey questions from 123 medical students who observed a preceptor during house calls to elderly homebound patients. Their comments included reflections on the medical treatment as well as interactions with family and professional care providers. Student insights about the social learning process they experienced during house calls to geriatric patients characterized physician role models as dedicated, compassionate, and communicative. They also described patient care in the home environment as comprehensive, personalized, more relaxed, and comfortable. Student perceptions reflect an appreciation of the richness and complexity of details learned from home visits and social interaction with patients, families, and caregivers.     

Bedside case presentations

STUDY OBJECTIVE: To determine current attitudes of patients, medical students, housestaff, and clinical faculty toward bedside case presentations. DESIGN: Survey using multiple-choice questionnaire and open comments for students, housestaff, and faculty, and a structured interview of patients. SETTING: Major teaching hospitals on the campus of a midwestern medical school, staffed by full-time faculty. PARTICIPANTS: 136 medical students, 58 housestaff, 66 faculty, and 73 patients. MEASUREMENTS AND MAIN RESULTS: 85% of patients liked the case presentation discussion at the bedside, but 95% of both students and housestaff felt more comfortable with such discussion away from the patient. Attending faculty were about evenly divided in preference, with the younger staff preferring the conference room setting. Most patients (88%) opposed rounds in the hallway. Duration of rounds of one to two hours was felt desirable by most, but 50% of students preferred a duration of less than one hour. For length of new patient case presentation, 60% of learners again favored brevity, less than 5 minutes. CONCLUSIONS: Bedside rounds are an opportunity to sharpen diagnostic skills and to demonstrate the art of medicine. They are undervalued by learners and younger faculty but appreciated by patients. The authors recommend that faculty improve bedside rounds by assessing team members' educational needs, by cultivating sensitivity and respect for the needs of all parties, and by assuring pertinence and brevity of bedside discussion.     

Does the Patient Appear Acutely or Chronically Ill?

ABSTRACT. The general appearance of 201 patients was assessed by a team of observers. Each patient was seen by two experienced physicians, two junior physicians and two medical students who stated whether the patients did not appear ill or whether the patient appeared acutely or chronically ill. The interobserver variation was considerable and the kappa-values ranged from around 0 to 0.75. The level of agreement did not seem to depend on the clinical experience of the observers. One experienced clinician assessed the patients differently from the others.     

Health and functional status and utilization of health care services among holocaust survivors and their counterparts in Israel

To examine differences in health and functional status and in utilization of health services between holocaust survivors and their counterparts; and (b) to investigate if holocaust survivor status is a significant predictor of health status, functional status, and utilization of health services. The study included 1255 respondents of whom 272 were holocaust survivors. Interviews were conducted face-to-face at the respondents’ homes. Participants were asked about their health (self-rated health and comorbidity) and functional (ADL and IADL) status, utilization of inpatient and outpatient health care services, age, gender, education, marital status, length of residence in Israel, and if they were holocaust survivors. Holocaust survivors, who were frailer and more chronically ill compared to their counterparts, visited their family physician and the nurse at the health care clinic more often than their counterparts did, and received more homecare services. Yet, there were no differences between them in the utilization of other health care services such as visits to specialists, emergency department, and hospitalizations. Holocaust survivors are more homebound due to more morbidity and functional limitations and therefore receive more health home care services that offset the utilization of other health services.     

Effect of a 1-week clinical rotation in palliative medicine on medical school graduates' knowledge of and preparedness in caring for seriously ill patients

OBJECTIVES: To assess the effect of a required 1‐week clinical rotation in palliative medicine during a 12‐week internal medicine–geriatrics clerkship on graduating medical students' knowledge and self‐assessed preparedness in caring for seriously ill patients. DESIGN: Historical control trial. SETTING: Mount Sinai School of Medicine (MSSM), New York, New York. PARTICIPANTS: Students from the MSSM classes of 2007 (MS07) and 2008 (MS08). INTERVENTION: MS08 was the first class to complete the required clinical rotation in palliative medicine. MS07 served as a historical control, having received only didactics in palliative care but no clinical rotation. MEASUREMENTS: Both classes were invited to complete an anonymous online survey designed to assess experiences and preparedness in caring for seriously ill patients and a 30‐question multiple choice knowledge examination. RESULTS: Fifty‐eight (55%) students from MS07 and 59 (51%) students from MS08 completed the survey. Students from MS08 rated their skill level in several areas of pain management and communication more favorably than did students from MS07. Mean scores on the knowledge portion of the survey were not significantly different between the two classes. CONCLUSION: Graduating medical students who had a 1‐week clinical rotation in palliative medicine had higher self‐assessed skills in pain management and communication than students who received no clinical exposure. A brief clinical experience in palliative care should be considered for integration into the curriculum at all medical schools.     

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.     

When 'something is wrong': a case for investigating vague health complaints

When a chronically ill elderly woman complained that she felt something was wrong, close attention and follow-up by physician and nursing home staff paid off.