Extend Alzheimer’s care from hospital to home

Boston hospital finds care continuum works best

Alzheimer’s patients and their families will cope better with the devastating disease if they are treated by a multidisciplinary team that continues care into the home, experts say.

"You need a large team to deal with the complex issues, the psychosocial issues, and an internist with 15 to 20 minutes to see a patient cannot deal with those issues," says Juergen H. Bludau, MD, medical director of Morse Geriatric Center in West Palm Beach, FL. Bludau also is a member of the Harvard Division on Aging in Boston and is an instructor of medicine at Harvard Medical School in Boston.

Bludau spoke about the critical need for a multidisciplinary team approach with Alzheimer’s disease patients at the Seventh Annual Alzheimer’s Disease Education Conference, held in Indianapolis this summer.

As part of the continuum of care, the team will refer cases to home care for home safety assessment, education, and some other aspects of treatment.

The ideal multidisciplinary team includes a geriatrician or internist, a nurse practitioner, a social worker, a geriatric psychiatrist, a behavioral neurologist, and a neuropsychologist, says Bludau. Until recently, Bludau had been a part of such a team at Youville Hospital & Rehabilitation Center in Cambridge, MA.

"In the team setting, we first diagnose what type of dementia a person has and treat accordingly," Bludau says.

Then the team addresses any specific behavioral issues and provides ongoing primary care for the patient, while the social worker educates the family.

It’s becoming a little more difficult in light of changes brought about by the Balanced Budget Act of 1997 for home care agencies to seek reimbursement for care of Alzheimer’s patients.

If the patient’s only diagnosis is dementia, Medicare will say the patient does not need skilled nursing care, says Karen Dick, PhD, RNC, director of Beth Israel Deaconess Medical Center Home Care in Boston.

"It may be hard to justify home care if the patient’s in early stages of the disease," Dick says.

When the agency receives a referral of an Alzheimer’s patient, the staff assess the case closely to decide if Medicare will reimburse for home care services. "We’re hospital-based and are able to absorb some of the visits that are not covered," Dick says. "But what often happens is these patients have other unstable conditions besides dementia."

So it’s important, Dick suggests, for the home care agency to handle referrals in these ways:

• When a physician or multidisciplinary team makes a referral, the agency should obtain as much of the patient’s medical history as possible and ask about secondary diagnoses, Dick says.

Alzheimer’s patients often have other, unstable medical problems, such as gait impairment, heart disease, and diabetes. "They may have been hospitalized and need a follow-up," Dick adds.

"We ask the referring person to say to us, What is it you’d like us to do? What is your greatest concern?’" Dick says.

• If the physician or team would like home care only to provide a home safety assessment, then the agency could send a physical therapist into the home. The physical therapist could meet Medicare guidelines by providing several services: safety assessment, safety education, and interventions to make the home safer, Dick says.

Bludau says the safety evaluation is essential, especially in the early stages of the disease when patients still might be driving a car. The potential for fires and falls also need to be assessed.

"Medicare won’t pay for an evaluation visit, so we have the physical therapist go out there and do interventions, teaching, and an assessment of the home," Dick explains.

• Check to see if the patient’s medications have been changed or if the patient needs therapy to maximize the patient’s functional ability.

• Clearly document how the patient is homebound. Alzheimer’s patients may not have physical limitations that prevent their leaving the home. But many are homebound because they are afraid to leave the home, or they are unable to leave the home for their own safety.

Once it’s determined that Medicare will pay for home care services, then the home care staff become part of the patient’s continuum of care.

The multidisciplinary Alzheimer’s disease team serves the patient in four domains, Bludau says. Home care may be involved with all of these areas. They include medical care, monitoring the patient’s daily activities, psychosocial issues, and patient/caregiver education. (See story on four domains in serving Alzheimer’s patients, p. 128.)

Dick says the home care team has many case conferences with the hospital team and relies on e-mail to keep physicians updated on cases.

"We make sure everyone agrees on a plan and that we have backup support," Dick says. The agency also may use a hospital psychiatrist and nutritionist who have dedicated hours to the home care agency.

"Our job is to keep the patient stable and out of the hospital," Dick says. "But it’s getting more difficult to justify the care and to get paid for it, so we’re trying to find alternative payment sources and even have some families pay us privately."

[For more information on multidisciplinary care for Alzheimer’s patients, contact:

Juergen H. Bludau, MD, Medical Director, Morse Geriatric Center, 4847 Fred Gladstone Drive, West Palm Beach, FL 33417. Telephone: (561) 471-5111.

Karen Dick, RNC, PhD, Director, Beth Israel Deaconess Medical Center Home Care, 330 Brookline Ave., Boston, MA 02215. Telephone: (617) 667-8236.]