Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today to highlight the Northwestern Medicine Geriatrics Home Care program is Dr. Alexandra Petrakos. She's an Assistant Professor of Geriatrics in the Department of Geriatrics at Northwestern Medicine.

Dr. Petrakos, it's such a pleasure to have you join us today. Tell us a little bit as we get into this podcast about the Northwestern Medicine Geriatrics Home Care Program.

Alexandra Petrakos, MD: Thank you so much for having me. It's a pleasure to be here. I will gladly talk about home care, which is near and dear to my heart. Northwestern Medicine Geriatrics Home Care Program is a team of clinicians who provide comprehensive primary care for older adults who are homebound or have significant difficulty leaving their home. So, currently, we have three physicians and soon three nurse practitioners, and a dedicated geriatric social worker who help to provide home care to the north and central regions. And so, we see patients at their home either in the community setting or in assisted or independent living facilities.

And then, basically, how do patients get to see us? Some patients have heard of our program, either online or through word of mouth or some co-residents at their facilities and have reached out to inquire. Sometimes we get referrals from our clinic or hospital colleagues. We're always happy to see if a patient will be a good fit for our program. And we do that through an intake process with our social worker. Because home care is such a limited resource, we do prioritize seeing people in the home who have difficulty with their basic daily activities like bathing, getting dressed, or ambulating to increase access to care for those patients who are effectively homebound.

Melanie Cole, MS: Such a big need. I mean, all over the country. This is one of those things, because geriatrics and home care specifically are so important for that independent quality of life, that feeling for someone that they're in a place where they are comfortable. Tell us about some of those specific services, because you mentioned the different people that are involved, you even mentioned bathing and homebound. So, tell us about those.

Alexandra Petrakos, MD: Yeah. So, I kind of already mentioned we provide primary care. We come into the home, do an interview, do a physical exam. We check vitals. We can do some simple wound care ourselves. We can coordinate having lab work drawn at the home, including blood work and urine studies. We can coordinate having home imaging completed, mostly including x-rays and ultrasounds. We coordinate very frequently with home health agencies who provide kind of more frequent home nursing visits, wound care, various therapies, physical therapy, occupational therapy, cognitive therapy or swallowing therapy, and sometimes even in-home counseling. These home health agencies are wonderful. We can also request home health aides, home health social workers, and other various team members who can come to the home.

In addition to home health agencies, we coordinate with home palliative care agencies. I have a home dentist that I refer to, home podiatry. I think those are most of the specialists that will try and come to the home. And then, some of us can also do certain gastrostomy tube exchanges or like a feeding tube exchange. We can do that in the home. Essentially, we try to do as much as we can, as much as we're able to in the home with some limitations on how much equipment. We don't have access to all kinds of testing equipment, but we do as much as we can in the home.

In addition to all of these kinds of outside services that we provide and that we try to coordinate, our geriatric social worker is invaluable, because our social worker can help connect patients with community resources, especially let's think about patients who might have cognitive impairment and, you know, their loved ones are their full-time caregivers. Our social worker does an excellent job of providing caregiver support resources. Connecting them with the Department of Aging to see if they qualify for caregiver hours or homemaker services or transportation services. That becomes incredibly important for our homebound patients and our home care patients because access to care is limited for whatever reason they have a hard time getting out of the house, whether it's cognitive or mobility. I'm just very grateful that we have a dedicated social worker who can help us connect our patients with resources in the community as well.

Melanie Cole, MS: That is such a comprehensive approach for seniors living in their own homes. Now, you mentioned so many specialties, Dr. Petrakos. How do you coordinate that care with hospitals and all those healthcare providers? How do you get everybody to show up? And even when you mentioned things like podiatry and physical therapy and OT, that's a lot of coordination.

Alexandra Petrakos, MD: Yes. We spend a lot of time coordinating care. So, I appreciate this question. For me, thankfully, we can communicate within our charting system. So, kind of practically the way this works is after I complete a visit, which we utilize the electronic medical record just like you would during a routine office visit. So, I complete my documentation, I put in all my orders, and then I just route my note to any provider who needs to be included. This is sometimes my Northwestern colleagues, non-Northwestern colleagues. I'll kind of message them as indicated with any updates or questions to help coordinate care.

I also receive a lot of communication from my Northwestern colleagues and from outside hospital providers about either visit like clinic visits or emergency department visits or hospitalizations. I will say, frequently, we have to kind of track down this information, which we're happy to do, because it's important as the primary care provider to have a full idea of what's going on with our patients and to kind of gather all of that information.

Since so many of our patients are truly homebound and have difficulty getting to any clinic appointment at all, I'm also very happy to coordinate getting any necessary testing done in the home to help my specialty colleagues who might be seeing our patients via telehealth. And so, that's something that I'm frequently communicating with my colleagues about. "FYI, I saw this patient, they have a telemed appointment coming up with you. If there's anything that I can do, if there's any testing you need that I can help get completed, please let me know." And so, that way we can kind of work together to get these vulnerable patients who don't have the best access to care, to actually help get done the testing and workup that needs to get done.

Melanie Cole, MS: I'm glad you mentioned telehealth, because ever since COVID, that has been such an advancement that has really helped rural areas, people that are homebound. I think it's just a wonderful thing and I don't think it's going anywhere. So, I'm so glad that you mentioned it, because especially for this population, I think that it's so important.

Now, along those lines, doctor, how do you involve family caregivers in the care plan and decision-making process? I remember helping my 97-year-old father to use his iPad for a televisit because he couldn't figure it out. But this is one of those things where the family members can come in handy, plus they're also being caregivers.

Alexandra Petrakos, MD: Yes. Absolutely. I couldn't agree more. Telehealth is wonderful and here to stay. And our caregivers and family members and healthcare powers of attorney, and even the staff at some of these assisted living facilities, we rely heavily on these individuals to help us during the visit and help us coordinate care after visits. So, I will say, most often, our home or assisted living visits are conducted with family members or caregivers present during the visit. And so, we communicate with everyone. It's kind of an open conversation with everybody present at the visit. If not present in person, we are happy to phone in the family either during the visit. And I would say more rarely we contact family members after the visit by phone to give them an update and to gather more information or by a MyChart message, the patient portal, to update them on the visit.

I will say it's a two-way street. The family members typically like updates from us. But also for me, these family members, caregivers, and facility staff provide so much valuable information, especially for our patients who have cognitive impairment, that it's a really important part of our visit, is speaking with family.

Melanie Cole, MS: Well, I know that, as a family member, we appreciate that kind of communication and it's so important so that we can feel that our loved ones are heard and well-cared for. So important. And do you have some strategies that you employ to enhance patient safety and prevent hospital readmissions because that's a big part of geriatrics care in general?

Alexandra Petrakos, MD: Absolutely. I guess this is kind of a two-part question maybe. Part of the home visit includes a home safety assessment where we physically review the patient medications, for example, look at their pill bottles, and assess how are they taking their medications, because there can be a lot of safety concerns with medications. Medication errors can contribute to hospitalizations, for example.

We assess their home medical equipment. "Let me see your walker. Let me see your wheelchair that you use." You know, ask patients to show us their living environment. "Where do you sleep? Where do you go to the bathroom and how do you get there?" Just to make sure that patients are safe, getting around their home and see if we can observe how they manage their daily activities.

We also examine the condition of the home. You know, we kind of spoke about how many of these patients have family members and caregivers who are very involved. Some of them don't. And some of them are having a harder time caring for themselves. And so, I need to know, are they able to manage things around the house? Are they able to get groceries? And, you know, I check the fridge to make sure that there's food that patients can be eating regularly and safely. So, those are a lot of the things we do during a home eval that's really unique to home care, because we have access. It's such an intimate environment, to be invited into somebody's home.

As far as preventing hospital readmissions, we don't necessarily measure a metric for this just yet, but we try to get updates after hospitalizations. And a lot of our patients are hospitalized outside of Northwestern. So, gathering those records and asking patients and family members to keep us updated throughout a hospital stay. If they happen to go to rehab after, before they go home, we want to know essentially when they get back to the home so that we can try and see them within a week of their discharge, ideally within a couple of days so that we can reassess any medication changes, get any follow-up labs that are needed, basically do that hospital follow-up. Make sure that the patient has everything that they need to set them up for success and prevent a re-hospitalization.

Melanie Cole, MS: Well, along those lines, do you have some protocols in place for managing acute exacerbations or emergencies at home? Tell us a little bit about that because caregivers and home healthcare workers might be present when one of those emergencies takes place.

Alexandra Petrakos, MD: Yeah, I'll speak for my team in the central region. So, that includes me and a nurse practitioner, Megan, who I work very closely with. So generally, I see patients at the home on Wednesday afternoons and Friday. And Megan sees patients Monday through Thursday, two days in the community and two days at an assisted living facility. So if a patient or family member calls our clinic to say, "Hey, we're having a bad day," we will see if we can rearrange our schedule to fit that patient on for an acute visit. We try to do this. It's not always possible. We try to mitigate things through communication, because Megan is a dedicated home care nurse practitioner, she's amazing, she manages a lot of these acute issues. And it's great thanks to her that things are handled either via phone or through messaging, or she can set up a visit and go and lay eyes on a patient.

Melanie Cole, MS: So, Dr. Petrakos, this is a really great program and so important as we've discussed the need. As we wrap up, what data or evidence do you have regarding patient satisfaction and outcomes in your home care program? And for other providers around the community that are thinking about getting involved or starting their own home care program, what's your best piece of advice about organizing all of this and really putting it all together?

Alexandra Petrakos, MD: I so appreciate this question. I don't know how great my answer is. I feel like we're still in a growth phase, quite frankly. Our home care program was previously run by one provider who was just trying to help people have access to care. She did a phenomenal job. Now, we've had the opportunity to grow our, program where we have more providers available. We're able to see more patients. And so, I think, over time, we're going to have more data on metrics of, are we able to reduce hospitalizations in this patient population because we're increasing access to care in the home setting? Currently, we don't have that data. We know that we have seen, in the past six to nine months, around 212 patients. We've had almost 900 individual home visits. I spoke to you before, Melanie, about the four or five M's of geriatrics. We keep track of things that are specific to geriatrics. So, do these patients have advanced care planning paperwork? Do we kind of assess them for depression, which is very common among older adults? We assess how many emergency department visits we've had. But I don't know that we have comparisons to kind of pre- and post-home care program. That's something that we're still working on gathering.

I think it's really important, you know, when I tell people that I do house calls, they say, "What? We didn't think that's been happening since like the '50s." There's been a swing back in favor of home care because of this idea that, in seeing patients in their home, we have the potential to reduce hospitalizations by increasing that access to care so that patients, whenever an issue arises, don't have to just call 911 and go to the emergency department, right? So, that's huge.

I think it's important to remind our colleagues that home care is not a money-making model, it's a money-saving model. And so, you're not going to go into home care to see hundreds of patients every week like you could do in the clinic. Of course, that's not the point. The point is to see these patients who don't have access to care, who are vulnerable, who are at risk of hospitalization, and exacerbation of their chronic issues because they can't see a provider in the clinic, and just help them manage those disease processes and keep them comfortable in their home, which is where they want to be. Nobody wants to be in the hospital.

So, I think insurance companies and institutions are gaining appreciation for this idea of a model that's going to help reduce the burden on the inpatient hospital system. I don't have data about patient satisfaction, but I do know that our patients are grateful to be seen in their home, to have access to a provider that they didn't have, and, honestly, that they didn't know that they could have. They didn't know that this was an option a lot of the time and so they're relieved and grateful for that. And I also know that it's a hugely rewarding part of my job, that I can provide this service to people in my community who otherwise might not have had access to care. And I appreciate that as a primary care doctor, as a geriatrician, as a physician.

Melanie Cole, MS: Dr. Petrakos, thank you so much. I love that you said money-saving, not money-making, because it is a needed service. And as you said, hearkening back to the older days when there were house calls, but I think it's a wonderful service. And I thank you for joining us and telling us about it today.

To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/geriatrics to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern medicine podcast for physicians. I'm Melanie Cole.