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Silver Linings: Medical residents make house calls for elders

New Hampshire Union Leader

October 29. 2016 10:45PM
Dr. Tida Lam of Concord Hospital speaks with Robert Dudley while making a house call at his Canterbury home on Monday. (DAVID LANE/UNION LEADER)

Helen Hutchins, 90, lives in a home not too far from downtown Concord. It's a home she's lived in for 58 years and where she's hosted two governors and a mayor.

"Not all at once, of course," she said.

Today, her home is also where she is getting her routine health care.

Hutchins is one of 80 or so frail elders receiving routine checkups at home from 24 second- and third-year medical residents at Concord Hospital under the watch of geriatrician Dr. B.J. Entwisle. Each patient has a team assigned to them that includes a behavioral health clinician, a social worker, and a nurse. The patients receive a house call from a resident about once every other month. Medicare gets the bill.

"If we go into the home and give them care then we are keeping them out of the emergency room, we are keeping them out of the hospital, and it saves money," Entwisle said. "It's a win, win, win."

Doctors making house calls is a long-gone tradition that went away in the 1960s, but is slowly making a return as our population grows grayer.

A 2012 Medicare pilot program called Independence at Home incentivized doctors to make house calls on frail elders in return for a share of the savings. In its first year, 8,400 patients treated at home nationwide saved Medicare more than $25 million - or $3,070 per patient. Legislation was filed by Massachusetts Sen. Ed Markey last summer to expand the program and make it permanent.

Still, house calls represent less than 1 percent of all of the nation's doctor visits, according to the American Academy of Home Care Medicine.

For Entwisle and her residents, the house calls are about learning, seeing the patient in their own environment, and listening to the patient's words and body. For the patients, it means getting the care they need without having to leave their home.

"It's wonderful. It's one less appointment I have to search for a ride for," Hutchins said. "It's more personal. There's something about being at home than being in an office."

The patients

Entwisle defines a frail elder as "you know it when you see it."

"Unexplained weight loss, slow gait, exhaustion," are some of the symptoms she points to. She said these patients are home-bound but live independently, meaning they can cook and use the toilet themselves. They usually have more than one chronic condition in need of treatment and really want to stay in their homes, she said.

Hutchins is one of those patients. At 90, she's amazingly sprightly and humorous. She's also legally blind and lives with osteoporosis and arthritis. She's been receiving house calls from Entwisle's team since 2003 and said she has loved each of the residents who has treated her.

"I feel like I've got the best of both worlds. I have residents that are new and fresh - not as in mouthy - fresh on new technology and medicine," she said. "Maybe they don't have 100 years of experience, but they have Dr. Entwisle and I benefit from all their expertise."

Entwisle describes Hutchins as a "tough Yankee who won't complain" which is why she and third-year resident Dr. Tida Lam are concerned. Hutchins has mentioned a nagging pain in her back and said the prescribed anti-inflammatory isn't working.

Lam and Entwisle consult before the home visit and decide Hutchins needs to come into the hospital for an MRI and will be getting a prescription for a low-dose opioid to help combat the pain.

The visit

Lam walks into Hutchins' Concord home carrying a doctor's bag - a black L.L. Bean messenger bag filled with about $400 worth of equipment.

"Everything you would need to do a basic physical exam," said Entwisle.

The resident's job is to look at the patient's gait, assess cognitive ability and look at the effectiveness of their medications. Entwisle urges them to look at the home and evaluate. Are there spots where someone may be prone to a fall? Can the patient get to the bathroom easily? How many flights of stairs are there?

"When you walk in the door, you see so much," Entwisle said.

Hutchins' home is immaculate and she's dressed up for the visit.

"I may be 90, but I do like to party," Hutchins jokes with Lam, as she describes the pain.

To which Lam responds, "She has more of a social life than I do."

As Lam examined Hutchins' back, she gave a little wince when the doctor touched a certain spot. Lam told her about the MRI appointment and explained the procedure.

Hutchins chalks up the pain to getting older. Lam tells Hutchins she is right about aging and her pains, but they need to find a way to manage them.

"We have to find the definition of a new normal for you," Lam said.

Help for the caregiver

Lam is fresh off a morning of an intense MLE exam to get her medical license when she makes her way to Hutchins' home. After an hour with Hutchins, she's off to her second stop ­- the Canterbury home of Robert Dudley, who at 93 is the town's newest recipient of the Boston Post Cane.

"The next step is you got to call the undertaker because that's where you are going if you get the cane," Dudley joked about the honor of being the town's oldest resident.

Dudley and his 92-year-old wife Virginia are both in wheelchairs and on oxygen. Lam has come to check his oxygen levels, his breathing, and foot pain. His daughter Melissa Dudley also has concerns about his Alzheimer's and whether it has gotten worse.

Melissa is struggling herself with a broken collar bone after a recent fall at her parents' house. She said it makes her life much easier to have someone visit them, instead of getting them out.

"You can call at any time and they call right back," Melissa Dudley said. "If you need something, they send someone right out."

His oxygen level is at 97 percent and thinks it means he can lose the oxygen, but Lam corrects him. She takes his blood pressure and it's a little high at 140 over 80, but says it might be because he is entertaining a large crowd in his home.

During the exam, he's talking about a house call he received when he was just a boy. The doctor diagnosed him with appendicitis and the entire bill for his surgery and stay was $7 - a bill he still keeps in his strongbox.

The experience

While the patients praise the benefits, Entwisle points to the experience the residents are receiving. Being on a house call takes away the hospital conveniences of costly diagnostics like chest X-rays, she says. It makes the resident use the stethoscope to listen to and really get to know their patient's heart.

"These bodies are different and you have to be different with them," she said.

Lam plans to practice family medicine and signed up for the program as part of her geriatrics rotation. She said it taught her to look at elderly patients differently.

"It teaches you how to be a better doctor. It teaches you to listen and it teaches you to hear," she said of the program. "I can't imagine what would happen to some of these patients if we forced them to go to the doctors."

Entwisle knows the 80 or so patients her group of residents are treating represent only a small portion of the state's frail elders.

"Our goal is to help them get better," Entwisle said. "We don't know how many frail elders are out there, but we know there are probably many, many more."

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