By Merin C. MacDonald
Frail geriatric patients are vulnerable to acute stressors including hospitalizations. They can become more vulnerable when they transition from one environment to another and need additional support when recovering from acute stressors. When patients go home from the hospital, they usually receive a follow-up telephone call within 48-72 hours of their discharge from the primary care or geriatric clinic as part of transitional care management. During this brief call, nurses check to see how the patients are doing. Although this call provides a touchpoint, there is no face-to-face assessment which can make it difficult to determine how the patient is adjusting to the transition back home. The majority of these patients then receive home health services for about 3-4 weeks which may include nursing care, physical therapy, and/or occupational therapy and a one-time visit with their primary care provider. When the home health services are complete, their follow-up care generally comes to an end. While paperwork from the home health visits is transmitted to the primary care and geriatrics clinics at the conclusion of their care, there is generally no other communication with providers, unless there is a serious problem. Thus, it is difficult for primary care and geriatric providers to assess whether or not the patient has made progress since their hospitalization.
In an effort to provide better coordinated and patient-centered care during the transition period, Stephanie Sison, MD, a geriatrician working at the Benedict Adult Primary Care Clinic and assistant professor of medicine in the Division of General Internal Medicine, and Kouta Ito, MD, a geriatrician and assistant professor of medicine in the Divisions of Geriatrics and Health Systems Science, are planning to partner with Mobile Integrated Health (MIH), a team of specially trained paramedics at UMass, to address the gaps in care between discharge and when home health services begin, as well as follow up after home health services are complete. The concept is that after frail geriatric patients are released from the hospital, MIH will go to the patient’s home within 48 hours to complete a medical and geriatric assessment and fill the gaps in care before home health services commence. In addition to the typical medical assessment which happens during post-discharge follow-up, the geriatric evaluation will include assessment of fall risk, safety, cognitive status (presence of delirium), medication appropriateness and adherence, and social support. When home health services are complete, MIH will return to the patient’s home to conduct a follow-up visit, assess their progress, and address needs that may have come up after their clinic visit and after discharge from home health services. During these visits, the MIH team will be in direct contact with the primary care or geriatric providers to discuss patient needs based on their assessment. The main goal of this collaborative initiative is to provide additional support for frail older adults in their recovery phase after an acute stressor, filling in the gaps that have been observed to commonly exist when older adults transition from hospital to home, ultimately improving patient outcomes such as reducing the incidence of rehospitalization.
Dr. Sison anticipates this collaborative initiative will launch at the end of June 2023.