House Calls for the Homebound
Physicians' Visits Increase Understanding of the Patient
More Americans are living into their 80s, 90s and beyond. In fact, people over 85 represent the fastest growing age group in the United States. As a result, caregiving is quickly becoming a hot political topic, rivaling crime and the economy.
For insight into the status of home health care in the United States, we contacted Edward Ratner, M.D, past-president of the 550-member American Academy of Home Care Physicians, headquartered in Edgewood, Md. He is an assistant professor of family practice and community health at the University of Minnesota and maintains a private practice in the Minneapolis-St. Paul area. He has been caring for the needs of homebound patients since graduating from the University of Chicago's Pritzker School of Medicine with honors in 1982.
In this candid and compassionate interview, Ratner discusses the current home care situation and its future for patients, their families and medical professionals.
CaregiverZone: What sparked your interest in home care medicine and geriatric medicine?
Dr. Edward Ratner: I trace my interest in geriatric medicine to growing up with my grandmother in Minneapolis. I was 10 at the time and one of four kids when she came to live with us. She lived until her late 90s and developed Alzheimer's disease. But she always had a sense of what was the right thing to do in situations based on her life experiences. We would talk about life and death and the pros and cons of nursing home versus home care. Later, during my residency training, I realized that I was more comfortable working with the elderly. To some extent, I credit my grandmother.
CZ: Choosing between home care or nursing home care can be an extremely emotional and difficult decision for many families. What advice can you offer adult children facing this decision for their aging parents?
ER: In general, people are more content if they can stay in familiar surroundings - their own homes. But environmental barriers such as the inability to drive, narrow stairways, bathtubs without safety railings and other items can make living in one's home difficult. Also, there is the risk of isolation. So, in some cases, assisted living apartments or nursing homes are better choices. One can actually be more independent in a nursing home and come and go as she pleases within a defined, safe space and have more people to socialize with than being home alone in a house.
CZ: What are your goals as president of the American Academy of Home Care Physicians?
ER: One of our academy's goals is to improve the level of care for people who are homebound. A recent study indicated half of all internists and family care practitioners made some home visits. We need to get more medical professionals to make house calls. We've worked with Medicare officials to get reimbursements for physicians making house calls. Now, we want Medicare to recognize the cost and time of the travel involved in making these home visits. We're making progress in recognizing the making of house calls as a meaningful part of medical practice.
CZ: What are the benefits for both the patient and the physician of house calls?
ER: Making house calls is a unique way of really understanding the patient, the family and what's going on in the home. The trust level improves and patients are more willing to follow medical instructions given by physicians who make house calls. I tell my medical students that the two most important things a physician must do during a house call is 1) look at the patient's feet and 2) look in the refrigerator. A number of diseases related to blood vessels and the nervous system show early signs in the feet. Sometimes, a person can't walk easily simply because their toenails need cutting. In the refrigerator, you get a good idea of what the person is eating and how well they can manage a household by looking to see if the food is fresh or spoiled.
CZ: What advice can you offer long-distance caregivers?
ER: Don't assume you know everything that is available in the community where your homebound parents or grandparents live. Turn to professionals in that community who can make proper assessments. Find someone in that community who can help - a primary doctor, a clergy member, someone from a community-based senior program. The biggest problem I see is that long distance caregivers think their parents may need move into a nursing home and not realize that there may be better options available in that community. Don't be afraid to seek answers and help.
CZ: One of the fast growing trends is the emergence of adult day care centers for seniors. What role do they serve?
ER: Adult day care centers, for the most part, work really well but are remarkably underutilized. But look at it this way: No parent would leave a young child at home alone. Yet a confused senior can be thought of as being as capable as a grade-school child. Regular access to nutritious hot meals and socialization provides tremendous benefits to seniors. People who join adult day care centers also tend to be lifelong members. This is a kind of service I see that complements home health care.
CZ: What trends do you see in home health care in the next five years?
ER: Crime was a big issue several years ago and then the national deficit. Now, caregiving will become the key political issue as the percentage of our population needing home care continues to soar. Our academy will push for tax breaks for caregivers. Improved technology will lead to two-way interactive services with the use of videophones, video cams and other remote monitoring systems in the home. As more people live into their 80s, 90s, and beyond, we will need to provide more community services that address Alzheimer's disease and other cognitive problems. Finally, I see home care expanding beyond meeting medical needs. More care agencies will assist homebound pay their bills, get proper-fitting clothes and shoes and take care of their financial investments.