From Baltimore to

From Baltimore to Louisville: Taking Care of Nursing Home Eligible Elders, Our Responsibility By Dr. Samuel K. Williams, III, M.D.

I trained at Johns Hopkins Bayview Medical Center under the tutelage of some great geriatricians (physicians for older adults) and with amazing colleagues at the community health center where I worked for two years, Total Health Care, Inc. My training at Hopkins was very broad based and covered every imaginable aspect of geriatric medicine and gerontology, including geriatric psychiatry and sub-specialty rotations.

Perhaps the most interesting part of my training experience was the Elder House Call rotation, which exposed me to the highly varied circumstances that elders face when they are homebound — essentially unable to realistically make trips to their doctor for reasons secondary to physical or mental disability among others. I made those house calls on foot, with minimal supplies and encountered patients in their "natural environment."

I encountered Chihuahuas, exotic birds, luxurious spaces, indigent spaces and even pistols. However, the patients truly benefited from the expert care that we were able to provide to them right in the comfort of their own homes. I really gained a valuable understanding of the situations that impacted older adults' health care when they were unable to leave their home and how to utilize a global perspective in making appropriate health care decisions for such home-bound elders.

Truly, if every patient was taken care of in his or her home by their physician then the care that would be provided for them would be drastically different from the care that is provided in an office. Perhaps the phenomenon termed "white coat hypertension," where a patient's blood pressure rises because of the stress of the doctor's visit, would no longer exist. Indeed, home blood pressure monitoring provides a more accurate assessment of a patient's blood pressure than in-office measurement. This type of assessment, in and of itself, could reduce inappropriate prescribing of antihypertensive medications.

As I explored the health care needs of older adults in the inner city, while working at Total Health Care (THC) I was able to interface with the community to provide much needed care to many elderly people. Total health care is a Federally Qualified Health Center (FQHC) that provides care to individuals who GetRuralLeaderMag.com | JULY 2017 5 lack insurance or are underinsured, and to others who choose to receive care there. Institutions like THC, including rural health clinics do a tremendous job taking care of patients who need health care the most, but the resources are limited and the patient population is unlimited, so to speak. In the area of home visits, funding is lacking.

The physicians at FQHCs have to carry a huge responsibility and take care of large numbers of patients, and they may go unrecognized for their efforts. In some cases, physician turnover may be high, but in others, physicians, for the love of their fellow man, remain in these institutions for longer periods of time. It is important to train physicians to return to their communities and to remain in them providing much needed care.

Even though I've moved from the "big city" to a small, rural community in Georgia, where I'm practicing "country medicine," my educational/practice experiences in Baltimore have expanded my perspective of providing care to vulnerable elders. For example, I’m now working at Jefferson Hospital in Louisville, Georgia. In this rural setting there is still a need to provide care for patients who, for reasons of disability, are unable to make it to their doctor’s office.

Elders that are unable to make it to their physician for medical reasons are considered “nursing home eligible.” This means that these patients could live in a nursing home if they, or their community, had the resources to provide nursing home care for them. One approach to providing care for nursing home eligible elders, which involves providing some care for the patients in their home environment (and also transporting them to their clinic appointments) is the Program of All-Inclusive Care for the Elderly (PACE).

PACE, from their website, “. . . is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.” I worked in a PACE Program in Boston, MA and in Baltimore, Maryland (as a trainee).

In the PACE program elders were picked up from their home in a van and transported to clinic. Continued on page 11