Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting the home care program at Northwestern Medicine. Joining me is Dr. Eliana Geller. She's a geriatrician with Northwestern Medicine.

Dr. Geller, thank you so much for joining us today. I'd like to start by having you highlight what challenges homebound older adults face that makes home-based geriatric care such an important service.

Dr. Eliana Geller: Sure. Well first, thanks for having me. I'm very excited to share about home-based care. Certainly, our homebound patients that we see really at the core of it is that they have a hard time leaving the house. Whether that's due to cognitive impairments or physical functional impairments, it's really kind of that getting out the whole to-do of leaving the house, getting to a car, getting out of the car for both the patient and, more often than not, their caregivers as well. That's what I would say is at the core of it.

Melanie Cole, MS: Yeah. There are so many challenges. Now, tell us about the home care program at Northwestern Medicine. How did this come about? And tell us about the services that you offer.

Dr. Eliana Geller: So, the home care program at Northwestern has been around for a while, well before I came into the picture. And we're working on and have been successful in growing it. Right now, the way that the team functions is we have two physician-APP dyads who are covering different geographic areas.

So, I and a nurse practitioner I work with, Rachel Lauber, we cover what we call the North Region, and that covers from Lake Forest to Rogers Park area. And then, another physician in our group, Dr. Alex Petrakos, and the nurse practitioner she works with, Aimee Halcomb, are covering more of the central area, and that's kind of like Rogers Park and south, and then all the way down to the South Loop. We would love to expand more, but obviously because we're only so many people and we have to travel to see our patients, we are a limited resource.

So, we see patients who are home or in assisted livings facilities. And we try to see them about every two months. And we go to their homes. We bring our supplies with us, which is our blood pressure cuff, our stethoscope, our pulse oximeter, sometimes some mild wound care supplies; lately, flu shots. And we come in and we do a standard medical visit with our patients. We're getting a history and physical, and we are able to do a lot for them in this way. We are able to order labs really through third-party agencies. We can get some imaging done at homes for simple X-rays and ultrasounds. And there's few, but some specialists that we can refer to that also come to the house to provide, or the home, to provide care in ways that can supplement what we can do. Because obviously, being in the home, there are limitations, but it's not completely limited.

Melanie Cole, MS: Yeah. But it's very comprehensive and such a great program. So, how does seeing a patient in their home change your clinical assessment and decision-making compared to an office visit? How does seeing how they live, where they live help with, especially with older people where you can assess risk of falling and the various things? How does it change your clinical assessment and decision-making?

Dr. Eliana Geller: When we get into someone's house, kind of immediately, you can get a sense for order versus chaos and how you walk in and you see what the challenges are just with moving within the space if the person, if the patient can move on their own. Oftentimes we have patients who are bedbound or have serious difficulty moving around their home.

So first, just coming in and being able to look at the space and say, "What are barriers, what are obstacles, and what are some things that just looking around we can make changes or suggestions of change?" Even things like switching out a regular bed for a hospital bed. We were able to just do that for a patient. She was in her 90s. She's very frail, and she was just laying on this flat mattress. And the family, she's becoming weaker for various reasons, and the family just couldn't manage her. They said every time they moved her, it hurt her. So, we put in an order for a hospital bed. That was pretty obvious just coming in.

And again, I'm the clinician. I see patients in these settings. I've seen patients in the hospital. You know when someone's frail and they're laying flat, what a huge aspiration risk that is, and that family members who only have this one person that they see all the time They don't have that sense. I mean, they may kind of know it, that it's not safe to feed someone while they're laying flat, but they don't always recognize that there's another option. So, that's one part.

I mean, we also come in and we ask family members or patients, "Show us how you keep your medications." And we can give suggestions or make recommendations on how to improve, you know, whatever systems they have to make them less complicated. That can be an opportunity pretty quickly to recognize that they need home health to come into the house and have a nurse come and help them organize their medications or even sort them for them.

We have our social workers too that are involved. We actually have our social worker, Michelle Clevenger, who does an initial intake for all of our patients when we get a referral or refer them ourselves to make sure they're appropriate for the program. And she stays involved if any services might be necessary and can help connect patients and caregivers or family members. So, things like homemaker services through the Department of Aging. She can help give resources for things like that if there's a lot of clutter or there's difficulty with preparing meals or things like that, or getting other, you know, Meals on Wheels or other resources of things to come into the house.

So, just seeing the space, the cleanliness, the order, disorder. And then we're also, besides for that, looking at just the patient, we're also looking at the caregivers. And a lot of times, that space is a reflection of the caregiver's level of stress, right? If there's a big pile of garbage or clothes that haven't been folded. And again, we come back every month or two and can see if that pile of clothes was put away or not. And it's a good indicator of how much stress these families are going through, because it's extremely hard to take care of somebody in the house and who has challenges leaving.

So, again, those social work resources. And I don't think we could do what we do without that. So, I'm very grateful to have our whole team, because it definitely takes a team to take care of these complex patients.

Melanie Cole, MS: Well, it certainly does. And so, I see how that changes your clinical assessment and decision-making. Are there any things you didn't mention there? You talked about clutter and caregiver stress, which is so important. Things that might go unnoticed in a traditional clinic setting. You mentioned medications. Are there anything that your keen eye notices when you're there that you would not in clinic be like, "Oh, well, they've got this or that"?

Dr. Eliana Geller: I think you get a pretty good sense of cognitively where a patient's at when they're in their own space also, because being in a doctor's office for some can be stress-inducing or a bit disorienting. But seeing someone in their own comfortable space and how they are around their own stuff can clue us a little better also on how they're doing cognitively.

If someone's living alone and some things may seem to be out of order, meaning just kind of random placement of things in the house that may not belong in the right places can clue us into some cognitive impairment. You know, sometimes patients will come into the office and maybe have a little coffee stain on their shirt or seem a little unkempt, but you know, you can't necessarily tell what maybe they missed their alarm or something and kind of had to run out of the house.

But when you're seeing a space and, again, can recognize the level of cleanliness and order can give a different picture of how someone is carrying on functionally and may be able to cover up in that regard when they come into the office and put on their best face.

Melanie Cole, MS: Are there certain patients for whom the home care program is really ideal? And what signs should prompt a physician to consider referral to this in-home program?

Dr. Eliana Geller: Yeah. So, our criteria actually are that someone needs assistance with at least two ADLs, and that's needing help with showering or grooming themselves, getting dressed, toileting, feeding themselves. So, if there's two of those things. And sometimes, you know, people and their caregivers and family members will say, "You know what? We really like to be in the office. We're happy to be here." But we can often tell when it's a challenge, an extra challenge to get into the office. And for just those reasons, outside of that, again, I mentioned we're limited geographically, so they do have to be in our geographic zone too.

So, I think it's just a matter of who has a hard time, and you see it, who has a harder time getting out. Is this patient coming in and needing a wheelchair from the office to get your clinic? Maybe they don't have that equipment. Maybe the equipment is really hard for their caregiver to handle and manage to get them physically into the office space. And sometimes too, these patients often see a lot of different specialists. They're tired. It's hard for them to get in and out and to take some of that load off so that it's an extra, obviously, convenience for us to be coming to them rather than them coming out to us.

So, I don't think these patients are so hard to recognize. But just knowing that that's available to them. Not everybody's used to it. It's not our traditional way that we see and care for our patients. It's kind of old school medicine in a lot of ways, so not everybody's ready to go back to that. But I will say all of the patients we see and their caregivers are extremely grateful for us coming in and taking a little bit of stress out of their lives and just one less thing for them to be thinking about.

Melanie Cole, MS: Well, it certainly does harken back to old school medicine, as you say. And I think it's just fantastic because there are a lot of people for whom a program like this is certainly ideal. Now, once those patients have been identified by referring physicians, how does the home care program coordinate with those primary care physicians, specialists, home health agencies that are sometimes sending those caregivers, social services, all of the things that support patients? How is that referral system and communication, how does that work?

Dr. Eliana Geller: So at Northwestern, for primary care doctor or any specialist, there's a lot of people that come in to see their specialist who don't have a PCP also. It's very simple. It's a referral order for home care. I think it's home care North and Central region, if I remember correctly.

There's also the option to send anybody in my group a message or me a message and say, "What do you think? Does this patient seem like they meet criteria? Are they appropriate for the program?" But that's just it. I mean, and coordinating the other home care or home health and all of that, I mean, that we do through—again, because we don't have our own—we do through third-party agencies, and that's often referrals that our offices help us send out to and just coordinating with patients' insurance and those kind of things.But it's not too complicated at all.

Melanie Cole, MS: Dr. Geller, this is such a great program and so comprehensive and really so needed today. As we wrap up, can you share a patient story that illustrates the impact of home-based care and how it can really have such an impact on clinical outcomes, quality of life, or the ability to age in place, and give us your key message about the home care program at Northwestern Medicine?

Dr. Eliana Geller: So, I have a patient who was actually starting to see me in my clinic in Deerfield who I was recognizing was just becoming a little bit more functionally dependent. He had a full-time caregiver at home, but seeing how challenging it was with him, wheelchair to walker to wheelchair, first of all, getting out, he was not able to dress himself anymore and dependent in really all of his IADLs. And he came into my office and we were just a regular kind of clinic visit, and more was just coming out about his functional decline overall and just, I think, as a factor of mostly age for him, because cognitively he was mostly intact but, you know, had some general deficits. He lived in Highland Park. It wasn't far and definitely within our range, and it was kind of easy. I just said, "You know what? We'll transfer you over to that program for us." And in a month or two our nurse practitioner, Rachel, was there to see him, and we've been seeing him every two months.

It's been much easier for him and his caregiver that they don't have to get out of the house to come in for visits. We've been able to coordinate. He had a newer diagnosis of diabetes that was requiring insulin later in life, and that became kind of complicated because it was new teaching and starting on insulin is not so simple. But we were able to coordinate with his endocrinologist and get him diabetes education, a lot of that through telehealth, and the coordination there was really helpful. And because we're able to see our patients more frequently, especially in that sense, we were able to also be on top of his blood sugars and his glucose control a little bit more.

And he didn't have to be leaving the house for that. And I think that that was a really helpful piece for him because he did want to be aging in place and staying in his home. And again, those inconveniences of having to get out of the house when it's really challenging and difficult physically can pay a toll and can also make people not want to go to the doctor when they really should be.

What I want other providers to know about the home care program is firstly that we are here. I think a lot of people don't know that we exist, but that we're here and we're here for when it gets harder for your patients who are aging to do simple things like get to the doctor's office. And if there are concerns otherwise of how things are going at home, we're there too. we want to work with the primary care doctor, and we want to be involved in that care. And we also help people transition as they age and get towards the end of their life.

I feel very grateful to be able to refer these patients to hospice because, again, these are generally more complex, sicker patients. We're able to do that for them as well and make sure that they're getting that comfortable care and that they're getting that support for both them and their family members into their final days. And being able to be in their space and see that, I think gives just a different perspective that you just can't get in the clinic.

Melanie Cole, MS: Thank you so much, Dr. Geller, for joining us and telling us about the home care program at Northwestern Medicine today. And 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. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.