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House Calls Can Be A Better Option For Some Seniors

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Dr. Eric De Jonge, a co-director of the Medstar Washington Hospital Center’s Medical House Call Program visits Elouise Cain, 90, in her Northwest D.C. home.
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Dr. Eric De Jonge, a co-director of the Medstar Washington Hospital Center’s Medical House Call Program visits Elouise Cain, 90, in her Northwest D.C. home.

Elouise Cain is a 90-year-old Washingtonian, who lives in a row house in Northwest D.C.  She has dementia and low vision, and she has a history of blood clots, high blood pressure, diabetes and kidney disease.  

Despite Cain's medical history, she is thriving.  Her daughter, Corrine Dubose, and her granddaughter, Monica Johnson, are fierce advocates for her. They document each medication and each blood test, and they take turns sleeping in a cot by her bed at night. They keep her mind as nimble as possible - practicing spelling and drawing with her.  In a quiet voice, Cain sings along with them.

"We have fun together," Dubose says.  "And I always say she would do the same for me. I know she would."

But Johnson and Dubose say Cain wasn't always doing so well.  Toward the end of 2009, she was living in a nursing home with a history of neglect accusations and health code violations.  For a while, it was on a federal list of facilities with persistently poor care.

House Call Program Lets Elderly Patients Stay At Home
Johnson and Dubose say they were able to take Cain home in large part because of Medstar Washington Hospital Center's Medical House Call Program. The house call team takes care of about 600 patients in eight D.C. zip codes. The patients are frail and have complicated medical conditions that prevent them from getting to office appointments.  Each patient is assigned a doctor, a nurse practitioner and a social worker, all of whom make house calls.  Johnson and Dubose say the program has allowed Cain to receive all of her care without leaving home, and as a result she hasn't been to a hospital since she became a patient.

"It saved my grandmother's life," Johnson says.  "From the picture when she went in there and the picture when she's here - it's a big difference."

House call programs... have an opportunity to build trust, to see what's going on, to really troubleshoot not only with the patient but also with the patient's family.

The program is designed to improve care and reduce overall medical costs.  But team members also serve as the first line of defense against elder abuse and neglect.  Doctors, nurse practitioners and social workers can watch how patients interact with caregivers.  They can even peek inside a refrigerator to see if there's food inside.  

Those with dementia and little social support are especially vulnerable.  Some suffer physical abuse or neglect. Sometimes family members gain control of their finances and begin taking their money.   In those cases, the house call team may be the only advocates the patient has.  Social workers can call a bank, a landlord or even Adult Protective Services investigators if they feel a patient is in danger.

"There's nothing like having a strong, devoted advocate in the patient's life," says Dr. Eric De Jonge, a co-director of the Medstar program.  "If there isn't a family member who can do that we find one who will provide that."

Marie-Therese Connolly, senior scholar at the Woodrow Wilson International Center for Scholars, has received a MacArthur Foundation "genius" grant for her work on elder abuse. She says DeJonge's team is playing a critical role in addressing abuse.

"House call programs are a really promising model in terms of addressing and preventing elder abuse because you go to where people are," she says. "They have an opportunity to build trust, to see what's going on, to really troubleshoot not only with the patient but also with the patient's family, or whoever else is part of the patient's community."

But the house call program is expensive and is not currently sustainable without grants and support from the hospital.  For instance, the program spends $40,000 a year on transportation, which is not covered by Medicare.  Time spent advocating for better housing or counseling family caregivers is not reimbursed either.  All of that leaves the program operating at a 25 percent deficit.

America's Growing Elder Population

Chart from Health and Human Services

Training And Understanding Elder Care Abuse
Elder justice advocates agree there are opportunities for doctors in more traditional health care settings to confront and prevent abuse as well.  But Bob Blancato, national coordinator of the Elder Justice Coalition, says a lack of education is part of the problem.

"There isn't the necessary forensic training going on in the medical side to know what to look for, and detection is the key to reporting which is the key to prevention," he says.  "What is missing from the picture is a cross the board commitment that everybody that's involved in providing aging services has to have some degree of training and understanding of elder abuse prevention."

Connolly says agencies that investigate abuse are also often underfunded and may not be able to handle additional referrals.  

"The risk of reporting without a proper response is that people will stop reporting," she says.  "It provides a kind of false hope."

Multidisciplinary teams like the House Call Program can work together to find a path forward.  Each Tuesday morning, the group's doctors, nurse practitioners and social workers gather around a conference table and share updates about patients one by one.  They offer suggestions - about medications to try or even the best time of day to visit a particular family.  

Jan Goldberg, a nurse practitioner on the team, says this approach is especially important for the most vulnerable seniors: those with dementia and complicated medical conditions who are often out of sight.

"They're up in the second floor bedroom," she says.  "They don't even get down and chat with their neighbor anymore in the front yard.  They're gone to the world.  So truly, we give care to the invisible. 

"We're all aging, she says, and we're all going to be vulnerable.  Advocates say figuring out how to confront that reality - to make the invisible problems of the elderly - more visible - is a challenge we're all going to face in the years to come.

Video:
Interview With Marie-Therese Connolly, MacArthur Foundation "genius" grant for her work on elder abuse

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