Medical Care for Homebound Older Adults: The Pros and Cons
Years ago physicians made house-calls. Today physicians are again making house-calls to visit older and frail elderly living in assisted living communities who find it difficult to physically transport themselves to a physician’s office. In theory this sounds like a good idea; why not provide medical care to those who find it difficult to leave a home-like setting?
The concept of making medical care more available to an older and frail elderly population requires little debate. Who would disagree with the premise that ongoing medical care for older and frail elderly, unable to leave a home-like setting, may prevent a need for more serious and expensive medical care like hospitalizations or nursing home care?
Millions of persons in the United States fall into the category of being homebound and unable to access medical care in a physician’s office. The great unknown is the quality of care provided by visiting physician offices. In my experience as an advocate for my clients, the concept of medical care for the homebound is convenient, but not always best for patients with complicated medical conditions.
Family members place loved ones in assisted living communities and never have to take them to another medical appointment. What a great idea to save time on the part of the caregiver, yet how does this affect the best interests and care of the care recipient?
What are the pros and cons? Have care standards been established for visiting physician practices? Who actually visits the care recipient to provide medical care? Is the care that family members as care recipients receive equal to the care the person would receive if they were physically able to see a physician in a traditional medical office? How are routine laboratory tests completed in a home-like setting?
Care standards have not been established for visiting physician practices. A project called The National Home-Based Primary and Palliative Care Network is working toward development of national standards and practices to support high-quality care for homebound patients. At present, since there are no care standards, the visiting physician category is an attractive business opportunity for many physicians wanting to escape the restrictions of operating a traditional medical practice.
In fact, while physicians oversee the care of patients living in assisted living communities they rarely visit patients or have direct patient contact. Nurse practitioners employed by the practice routinely visit patients and depending on the state in which one lives, have less or more ability to write prescriptions and make medical care decisions. This leads to a question of preference and personal opinion. Do you believe a nurse practitioner is as skilled as a physician to provide medical care?
In my personal experience I have come into contact with visiting nurse practitioners who are excellent medical providers; some I prefer over the physician of the practice. I have also experienced visiting nurse practitioners who made frequent mistakes in prescribing medications to which my clients were allergic, those who changed or discontinued medications without my approval and others who want to take the easy route to prescribe hospice for my clients without having any true medical diagnosis for this decision. Why take an easy route, because practices are paid a set amount by insurers to manage patient care. More tests may equal lower profits.
Let’s compare visiting physician practices of today to non-medical in home care, offering companion type services. Both offer services that provide individuals to visit home settings. The challenge for both, in my opinion, is that the individuals visiting care recipients have little oversight and while nurse practitioners certainly have many more years of education the home setting is still unsupervised.
In a traditional medical practice if a nurse practitioner has a question, he or she walks down the hall to consult the physician and receives an immediate answer. In a visiting medical practice the nurse practitioner does not have immediate access to the physician. Decisions made by the nurse practitioner may not be immediately reviewed by the physician of the visiting practice or may not be discovered by a family member until after the decision was made. In non-medical home care, the caregivers’ only contact with a supervisor may be dropping off paperwork on a weekly basis for payroll.
How might this lack of supervision by a physician for a nurse practitioner or by the supervisor of the non-medical home care company for the caregiver affect the quality of care provided to a care recipient? Since non-medical home care is not a new industry and the industry is regulated, the challenges of non-supervised employees are well-known. Since visiting physician offices are relatively new, but gaining in popularity the challenges of non-supervised employees remains to be identified.
In my experience, some practices are growing at such a rapid rate that the founding physician cannot keep up with expansion pains. Rapid growth results in sub-standard care being provided to patients in home-like settings, which supports the need for the development of national standards of care for visiting physician practices.
As in all situations related to care of a loved one, the caregiver must become an advocate and question recommendations. You know your loved one best and being involved in the intimate details of their care is the only way that you will truly ensure that they are receiving the best care — whether the care be medical or care in an assisted living community. Family caregiver involvement and advocacy are critical.
What then, if a homebound person requires lab work or medical tests? Most assisted living communities have contracts with visiting labs who are able to complete blood draws, perform x-rays and complete routine medical tests. Other ancillary services are also available at assisted living communities like visiting dentists and optometry services providers.
We are a society who prefers convenience. As the concept of medical care for the homebound becomes more common through the rise of visiting physician practices, it is important to realize that convenience comes with compromise. For a care recipient who is reasonably healthy, a visiting physician or nurse practitioner may be ideal. For a care recipient with complicated medical needs, the traditional medical office may be the better option.
For information and articles to support your caregiving journey, visit my website TheCaringgeneration.com. My book, The Caregiving Trap: Solutions for Life’s Unexpected Changes, offers ideas and support to help you become an advocate for your loved one.