Atrius Health Clinicians Testify Before Joint Legislative Committee

| Posted On Oct 06, 2015 | By:

Daniel Oates, MD, Director of Geriatrics and Extended Care and Deborah Nolan, NP, Acting Chief of Geriatrics recently testified before the Joint Committees on Elder Affairs and Mental Health and Substance Abuse at the State House and showcased the system of healthcare for seniors at Atrius Health, including the home-based primary care program.

The informational briefing focused primarily on issues surrounding geriatric mental health, but also covered a wide variety of topics including housing, legal issues and overall access to services that create barriers to seniors accessing care in the community.  During his opening remarks, Dr. Oates noted that approximately 52,000 Medicare beneficiaries receive their primary care from an Atrius Health provider, and several thousand others see Atrius Health specialists. In addition there are approximately 40,000 patients receiving home care/hospice services from VNA Care Network & Hospice.

Dr. Oates described the variety of medical conditions many geriatric patients may have including diabetes, congestive heart failure, COPD, and also shared the variety of mental health issues some patients face such as dementia, Alzheimer’s disease and depression.

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“While we treat a significant number of patients in the office-based setting, we have found that many of our patients are simply not able to come to the office for appointments for a variety of issues including lack of transportation, physical limitations, or underlying health issues.  As a result, Atrius Health has built a home-based program that I am part of, where providers actually go to a patient’s home to care for the patient” Dr. Oates said, “Home visits provide us with a unique window into our patients and their lives that we simply cannot appreciate in the office.  By going into the home, one can witness first-hand the environmental challenges our patients face such as long narrow staircases, cluttered living environments, loose throw rugs that present significant tripping hazards, and disorganized medications.”

Talking about the advantages of the home-based program, Dr. Oates said “when a member of the team enters a patient’s home, especially for the first time, we often see ourselves as detectives – looking for clues that may help explain why they keep ending up in the emergency room or why they are not responding to treatment as expected.”

Dr. Oates noted that physicians and nurse practitioners are only one part of the team important to caring for geriatric patients. The care of the geriatric patient requires an integrated team of nurses, therapists, community case workers and home health aides who communicate well with each other, but all too often care is fragmented or nonexistent, such as in the case of home dental, ophthalmology and audiology.  He further told members of the committee that there are not enough providers who do home visits to meet the need that exists, especially with the increasing prevalence of diseases such as dementia.

Rep. Denise Garlick, House Chair of the Committee on Elder Affairs, asked how Atrius Health is able to provide this unique service to its patients. Dr. Oates shared that because Atrius Health participates as one of the Medicare Pioneer Accountable Care Organizations (ACOs) we, unlike many providers, take global payments. This allows Atrius Health clinicians to focus on providing the care and resources to patients at home without having to worry about reimbursement.

Debbie Nolan spoke passionately about her role as a nurse practitioner in caring for patients who are part of the home-based primary care program. She explained that the program was originally created to see patients after they had been released from the hospital or a skilled nursing facility as a way to help prevent a readmission. The home-based program has now grown to include more than 500 Atrius Health patients.

Nolan told legislators on the committee that while initially patients might be referred to the program by their primary care physician because of a clinical issue, the home-based primary care team often finds undiagnosed mental health issues such as dementia, depression, anxiety, substance abuse, hoarding and loneliness that are impacting the patient’s ability to care for themselves at home. In addition, team members frequently find that patients are experiencing difficulties in managing changes in their medications that can lead to serious health complications.

Nolan then recounted a story of a 91-year-old Atrius Health patient who entered the home-based primary care program as a way to highlight how successful the program can be for patients not only in terms of their health, but also their quality of life.  When “Mary” was first referred to the program, she had been hospitalized repeatedly for dehydration and dizziness related to high blood pressure. “Mary” had lived in the same apartment for more than 50 years, but as she had aged, she found it more difficult to get up and down the stairs meaning she often did not drink enough fluids because her kitchen was downstairs. As time passed, many of the social supports she relied upon were no longer there.

The home-based primary care team at Atrius Health was able to secure a visiting nurse to assist “Mary” with managing her medications, which reduced her visits to the emergency room. In addition, she was connected with a social worker who helped the patient reconnect with her church and transportation arrangements were made so she could once again attend services.

“When Mary reconnected with her church, she had a reason to live again. With the help of her church, she moved to a retirement home where she is doing very well. Mary is not atypical,” Nolan said, “Depression and early signs of dementia are often undiagnosed causing patients to spend many days in and out of hospital with symptoms associated with depression.”

For more information about the Atrius Health home-based program, read our previous blog post, Caring For Patients When They Can’t Get to the Doctor’s Office.

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