Visits keep frail elderly out of hospital

Model integrates care across the continuum

Frail elderly patients are able to stay in their homes, thanks to home visits by an interdisciplinary team from Boston University's Geriatric Service at Boston Medical Center.

The home visits are part of an integrated model of care across sites of care, including a geriatric outpatient clinic, a nursing home program (both sub acute and long-term care) and an inpatient geriatric service staffed by geriatricians, nurse practitioners, and a discharge planner, according to Maureen Russell, RN, BC, MPH, CCM, a certified geriatric nurse and nurse case manager in the Geriatrics Home Care Program.

The Home Care Program provides care for homebound patients age 70 and older who live in the Boston inner city. Many are low income and non-English speaking, and uninsured or underinsured. The majority are female who rely primarily on Medicare. Some are dual eligible and receive Medicare and Mass Health, the state's Medicaid program.

Pat Takach, RN, MA, home care nurse case manager says that each home care team includes a nurse case manager and a board certified geriatrician and is assigned to a particularly geographic area. Physicians visit the patients every two to three months, depending on the patient's preference and condition. The case managers often see their patients frequently at first, then as needed. The case managers complete a geriatric nursing assessment on the first visit and assess the home environment, barriers to safety, social support, pain issues, and potential for falls. "The first real issue is to look at the medications for duplications and work with the geriatrician to consolidate them, and limit the number of times a day the patients have to take their medication. We also conduct medication reconciliation at every visit," Takach says.

If the patient can manage taking their own medications, the case managers may suggest using medication planners set up for a week or two at a time. They work with the caregivers to ensure medication adherence.

The nurse care managers think outside the box to come up with ways to help the patients stay at home, minimize hospital admissions or transfers to an extended care facility. For instance, they have arranged pest extermination services, purchased durable medical equipment, arranged homemaker services, and arranged installation of air conditioners in the homes of patients with chronic obstructive pulmonary disease. For one elder who could not negotiate the stairs to her third-floor walk-up apartment, the case manager arranged for installation of a chairlift.

One patient who is completely deaf requires anticoagulation therapy. The case manager installed a fax in the patient's home in order to communicate blood thinner dose adjustments efficiently. The nurse practitioner and the case manager take turns going to the patient's home and filling the pill box with doses of blood thinner based on her International Normalized Ratio (INR) levels.

The ultimate goal is to keep the patients in their homes as long as possible and to support them and their families as they move through the continuum of care. Recognizing that caregiver stress can be a real problem, the case managers encourage self-care for caregivers. For example, they may arrange adult day care services and transportation to minimize caregiver burnout.

"Many patients are being cared for by adults who are older than 70 themselves, and have their own medical problems, along with the responsibility of taking care of their parents. We evaluate the caregivers for services, as well and get them help when they need it," Takach says.

The case managers typically carry a case-load of about 100 patients. They usually visit their patients two days a week, often accompanied by medical students from Boston University School of Medicine. The remainder of the week, they work on service coordination, phone calls, research projects, and lectures for students. They attend Friday morning educational conferences with the entire clinical staff in Geriatric Service to keep staff up to date on best practices.

Russell adds: "We stay with our patients for life. We try to stay ahead of the curve and prevent readmissions and keep the patients safe at home. When we can keep the patient in their home, the patient is happier, the family is happier, and it reduces costs to the healthcare system."


For more information contact:

  • Maureen Russell, RN, BC, MPH, CCM, Nurse Case Manager in the Geriatrics Home Care Program at Boston University Medical School. E-mail:

Collaboration is key to managing seniors

Program extends across levels of care

Frail elderly patients are vulnerable for exacerbation of their conditions and readmissions to the hospital as they transition between levels of care, points out Maureen Russell, RN, BC, MPH, CCM, a certified geriatric nurse and nurse case manager in the Boston Medical Center Geriatrics Home Care Program.

The Geriatrics Home Care Program is part of Boston University Medical School's Geriatric Service, which provides integrated care management for seniors in the geriatric inpatient service and outpatient clinic at the Boston Medical Center, in area skilled nursing facilities, or in their homes. "Patients tend to move among our four sites of care as conditions indicate. Many start receiving services in the geriatric clinic, and as they become more fragile and perhaps homebound, they receive home care from geriatricians and case managers. If they are admitted to the hospital, they may be discharged to one of the 10 nursing homes we serve. Clinicians at all levels of care collaborate to ensure that the patients get the care they need," Russell says.

The home care program is staffed by six nurse care managers who work closely with geriatricians and precept fourth year medical students from Boston University School of Medicine. The geriatric clinic is staffed by two nurses specializing in geriatrics. Five geriatric nurse practitioners see patients in the skilled nursing facilities.

The service is available to patients 24 hours a day, seven days a week. The hospital operator answers the program phone after hours and pages the geriatrician on call.

The geriatric inpatient team follows patients in need of acute care. When patients are discharged, they transition to the home care program, the skilled nursing facility team, or an outpatient clinic, depending on their needs, Russell says. When patients are discharged to their home, a resource nurse makes a follow up call to review the discharge plan. If patients are discharged to a skilled nursing facility, a nurse practitioner or physician sees them within two days.

The home care case managers work closely with the skilled nursing facility program which includes a geriatrician and a geriatric nurse practitioner, as well as the treating team at the geriatric clinic and the hospital-based geriatric team. When patients are ready to return home, the skilled nursing team coordinates the discharge with the home care case managers.

Pat Takach, RN, MA, home care nurse case manager says: "Many times, it's difficult to discharge frail elderly patients back into the community. If the nursing facility questions whether the senior could be safely discharged, we go to a family meeting and discuss the best plan with the nursing facility staff." The program has a palliative care component which the case managers can call on to help managing the patients' care when appropriate.

On Fridays, the entire clinical staff in the Geriatric Service meets formally and informally to discuss patients, brainstorm solutions to difficult cases, and share information about the patients who are transitioning between sites of care. For instance, if a patient is leaving the hospital and going home, the physician discusses the case with the care manager who is better prepared for the home visit." Russell adds: "The meetings help us improve transitions between levels of care by making sure everyone is on the same page and facilitating communication between the teams."