Matter, Colleen A. PsyD; Speice, Jenny A. PhD; McCann, Robert MD; Mendelson, Daniel Ari MS, MD; McCormick, Kevin MD, PhD; Friedman, Susan MD, MPH; Medina-Walpole, Annette MD; Clark, Nancy S. MD
Physicians-in-training discharge many older patients from the hospital, but residents often have little knowledge of the fate of the patients they send home, how the discharge plan is applied once the patients return to their homes and community, or the difficulties encountered by the patients and their families. At discharge, older persons are at increased risk for decline in Activities of Daily Living (ADL), rehospitalization, institutionalization, and subsequent mortality.1–3 Many factors influence the success of an older adult's hospital discharge, including home medication management, environmental factors, and support systems. Although studies have demonstrated that attention to comprehensive discharge planning has improved posthospital outcomes for older adult patients, nothing has been written about using home follow-up after discharge to train internal medicine residents in these areas.4,5 In fact, based on a recent survey, fewer than half of all internal medicine residencies provided a single lecture on home visits, and one third of internal medicine residencies offered absolutely no home care instruction.6 Teaching residents about the risks and providing them with direct experiences with the successes and complications of discharge planning can sensitize them to the special needs of older adults in the transition from the hospital to home.
The home visit experience for internal medicine residents at the University of Rochester School of Medicine and Dentistry occurs during their internship year in the context of a two-week geriatrics rotation centered at a community teaching hospital specializing in the care of older adults. During this rotation, the first-year resident participates in a variety of ambulatory geriatrics activities. The goal of this rotation is to expose the first-year resident to the care of older adults in a spectrum of settings. The addition of the Hospital to Home pilot program allows the resident to follow a patient during the hospital discharge process as the patient returns to his or her living situation or to a rehabilitation facility.
The Hospital to Home pilot program was introduced as a component of the geriatrics rotation in July 2001. Since its introduction, 23 internal medicine residents have completed videotaped home visits, and approximately 72 residents, ten medical students, and several family medicine residents have participated in home-visit conference presentations using this video footage. Two psychology fellows have been involved in the project to date.
Faculty with specialized training in behavioral medicine and geriatrics are involved in different segments of the project. The physician faculty includes the geriatric medicine rotation director, director of the acute care for elders (ACE) unit, the chief of medicine, and chief residents. Behavioral medicine faculty includes a family therapist and a primary care family psychology fellow. Although the floor staff is not directly responsible for resident teaching during the Home to Hospital exercise, residents often have opportunities to spend more time learning from these staff members than they would during a typical discharge. The fellow (who is a nonphysician behavioral health provider) facilitates these interactions by helping the resident identify treatment team members from whom they may learn additional information. The level of interaction with nonphysician staff varies on a case-to-case basis, depending on the residents' needs and the patients' disposition plans. Ongoing feedback from residents, faculty, and students has helped shape the program into its current three-segment format: (1) hospital assessment of the patient; (2) home assessment of the patient; and (3) resident conference presentation.
Hospital Assessment of the Patient
The medical director of the ACE unit uses the morning report and attending rounds to identify a geriatric patient scheduled for discharge from the hospital. Either the medical director or a behavioral medicine faculty member discusses participation in the project with the patient.
After consultation with the behavioral medicine faculty, the first-year resident greets the patient in the hospital and obtains informed consent for the interview and videotaping. The program has been limited to patients who can consent to participate. During the predischarge interview, which is videotaped by the behavioral medicine fellow, the resident inquires about the patient's understanding of the hospitalization and any concerns about discharge planning, and then completes the following assessments:
▪ Folstein Mental Status Examination
▪ gait and transfer ability, illustrated by “get up & go” task
▪ ADL, Instrumental Activities of Daily Living (IADL) (forms available upon request)
▪ social support history, including friends, family, community, services
▪ medication management plans, including acquisition, payment, organization, and administration of medication after discharge
▪ environmental history, including physical layout of outpatient environment, assessment of fall risk, how long at current residence, etc.
▪ need for durable medical equipment and supplies, before admission and at discharge.
The resident documents any agreement or concerns that he or she has about the existing discharge plan. With the patient's consent, the resident also talks with caregivers, family members, and the multidisciplinary discharge team to determine the caregivers' understanding of the hospital course and any concerns they might have.
Home Assessment of the Patient
The home assessment generally takes place within one week after discharge. During the home visit, the fellow records a brief video of the interview, the physical layout, any potential safety hazards, and any adaptations that the patient or family has made to the home. The resident discusses with the patient, and family if available, whether the previously stated concerns or additional concerns have arisen, and he or she observes the physical environment for the following:
▪ home safety
▪ gait and transfer ability
▪ demonstration of functional status in the home (ADL, IADL)
▪ social support services used or needed
▪ medication management, including storage, organization, administration
▪ access to and use of durable medical equipment
▪ unforeseen complications.
(When a patient has been discharged to a rehabilitation or nursing-care facility, the postdischarge visits to these facilities have been instructive, but in different ways than seeing the patient return to his or her own home. The resident observes the patient's experience of rehabilitation facilities and use of adaptive devices and then views the active recovery process.)
Resident Conference Presentation
After the home visit has been videotaped, the first-year resident and behavioral medicine fellow present to a group of faculty, senior residents, and medical students in a noon conference format. The first-year resident reviews the predischarge assessment with the group, using portions of the videotape for illustration purposes. The group is then asked to predict and record any potential pitfalls in the patient's discharge plan. They are also encouraged to make predictions about the patient's physical environment, social supports, and medication management and cost. After this discussion, the first-year resident and the behavioral medicine fellow present the findings of the home-visit videotaping to the resident group. The geriatrics and behavioral medicine faculty then facilitate further discussion pertinent to the outcome of the case, the educational objectives, and the points the resident learned from the experience.
The following vignettes demonstrate how home visits provide additional information to residents. These cases highlight the importance of understanding patients' biopsychosocial functioning. (Any identifying information in the following vignettes has been disguised to maintain the confidentiality of participating patients.)
The first-year residents are encouraged to consider the physical environment of the patient's home and neighborhood and to identify any safety risks or accommodations the patient makes to facilitate ADL/ IADL. The resident notes such specifics as the entrance to the home, flooring, lighting, furniture, stairs, room layout, and distance to the toilet.
Case 1. After a pleasant hospital interview with an active 72-year-old woman returning home with the addition of a walker, the resident had little concern regarding her ability to function at home with the planned support of her visiting daughter and home nursing. A visit to Mrs. W's home revealed a few minor exterior obstacles such as a garden hose across the sidewalk. Once inside the home, however, the resident noted an exceptional amount of clutter. Although the home was clean, the space was much too small to manage effectively the patient's lifetime accumulation of belongings. Items were stacked along walls and upon tables and chairs throughout the home. There was limited room in which to walk and even less room for the patient to navigate with the assistance of a walker. The resident team discussed how the obstacles also impeded Mrs. W's use of the kitchen and greatly increased her risk of snagging her percutaneous transhepatic biliary catheter while ambulating along the path to her bathroom. The visit and video also illustrated areas of the home that Mrs. W could not access with her walker.
As one resident observed, older patients sometimes overstate their abilities to care for themselves independently in their homes. A home visit and direct conversation with caregivers and family members or other close supports can reveal that patients have more limitations in daily functioning than they report in the hospital.
Case 2. Mr. L was eager for discharge and described in detail his elaborate cooking skills and daily activities. When the team visited him in his home, his daughter, who was visiting from her home an hour's distance away, expressed concerns about his limited eating habits and apparent lack of motivation to return to previously enjoyable activities with neighbors. When confronted by his daughter about the differences in their reports, Mr. L agreed that his cooking consisted of making “grilled” cheese sandwiches by putting a slice of cheese between two pieces of bread browned in the toaster. In addition, although he talked about many activities he was hoping to return to with his neighbors and in his yard, when the resident asked him to demonstrate how he walked to the bathroom, he took only about ten steps before returning to his chair and oxygen. The resident later explored whether these limitations might be related to or could lead to depression. In her presentation at the resident conference, she remarked about the importance of actually seeing the patient's functional status in the home setting rather than relying on the patient's report. She also discussed how gender interactions, cohort expectations, and cultural background might affect an older adult's report of functional status.
One of the core educational goals for first-year residents on the geriatrics rotation is to learn about the patients' abilities to acquire, store, and administer their medications. Residents and attendees of the noon conference are often surprised by the costs associated with various medications and that, for some older persons, paying for needed medications is a challenge. Medications are often prescribed to patients, but questions regarding how the patient will pay for, pick up, or manage the daily dosages of different prescriptions are never asked. Some patients have the assistance of a family member or caregiver in the home, but others must manage these tasks independently.
In addition, while visiting a patient's home, residents have the opportunity to review the “medication stockpile” that often has been stored up for many years. During one such visit, a patient provided a plastic shopping bag full of bottles accumulated from decades of prescriptions. The patient was unclear what each bottle was for, however she was reluctant to part with any of them in the event that they would be needed later. As the resident group was viewing this portion of the video, many residents remarked that they were sure that their patients also had such a collection in their homes and that they would begin asking patients to bring their bags of medications with them during their next visit. A faculty member said he has a desk drawer that he has filled with old prescription bottles brought in by patients; he uses these collections as a teaching resource for residents.
Case 3. In light of the disorganization and confusion our resident teams have witnessed regarding patient medication management, they expressed relief as they watched the videotape demonstrating that Mrs. J had medication bottles well organized and stored within easy reach. Additionally, she was able to accurately report from memory the names and dosages of her prescriptions. Fortunately, this home visit coincided with her regular medication time, so our team was able to observe her administer her doses.
At first, Mrs. J was unable to remove the safety cap from a new bottle of medication. The resident assisted with this task. As she selected pills from the bottle, Mrs. J repeated her daily dosage accurately from memory. The resident noted that, although she was reporting the correct dose, she was about to administer an overdose of her medication. After further inquiry, the resident discovered the problem: Mrs. J was accustomed to taking two half-dose tablets. At her latest refill, the pharmacy filled her prescription with tablets twice the previous dose, so she would need to take only one. Mrs. J did not recall having a conversation with the pharmacy about this change and was so accustomed to her former regimen that she had been unknowingly taking too much of the medication for several days.
RESIDENTS' FEEDBACK ABOUT HOME-VISIT CONFERENCE PRESENTATIONS
Many residents and medical students have commented about the added understanding they have gained from hearing patients discuss their health and discharge concerns while viewing them on videotape in the context of the patients' own home environment. For example, it was easier to understand why one gentleman refused to use the commode recommended in his discharge plan when the team observed its placement in the very public family room of his home.
In comments during and feedback after conference sessions, residents have stated that exposure to patients' homes, in-depth conversations with patients' families, and guided discussion during the home-visit presentations have altered the manner in which they plan to care for older patients in the future. A heightened awareness of sensory deficits, barriers to communication, importance of working in teams, and participation in discharge planning in the hospital are frequent themes the residents raised. Residents have also identified changes in the way they conceptualize discharge planning by thinking differently about outcomes. Many of the resident conference presentations have spurred discussions that dispel myths about older persons by illustrating adaptive functioning and resiliency during recovery at home. For example, residents have commented on the physical appearance of frailty they observe in predischarge patients dressed in hospital gowns and lying in hospital beds. This contrasts significantly with the functional image of that person dressed in his or her own clothing, performing routine activities in the home.
INITIAL EVALUATION AND CHALLENGES
With the structure outlined here, the Hospital to Home educational program is replicable in a range of residency settings. The support of inpatient and outpatient geriatrics education leadership has contributed to the success of our program. This includes the involvement and support of the geriatrics rotation director, ACE unit director, the chief of medicine, and the chief residents. An overwhelmingly positive view of the program, spread through word of mouth from residents who completed the experience either as interviewers or as participants in the conference presentations, also became a driving factor in the enthusiasm and success of the pilot program.
After the initial start-up cost of the program, including digital video recording, editing, and presentation equipment, the program requires minimal financial support. Digital equipment has many benefits over other forms of audiovisual recording and editing, including ease of use, smooth presentation, and better archival quality and durability for ongoing teaching use. Some programs may already have access to such equipment and technical support through their training programs. After the initial scheduling challenges were managed, the shared faculty time from the department of medicine has also been sustainable. Integrating any new experience into an existing residency rotation can be challenging from a scheduling perspective, and this program is no different in that respect. Strong support of educational leadership has eased some of the challenges of coordinating patients' and participants' time around other internship activities. Scheduling flexibility demonstrated by leadership, residents, and fellows to facilitate home visits has been invaluable. However, due to demands on residents' time during training, inevitably some residents may be unable to participate in the entire three-part experience.
DISCUSSION AND FUTURE DIRECTIONS
Residents' previous experiences with being video recorded in a training context vary widely. Depending on the quality and frame of those experiences, some residents have had reservations about being videotaped. Behavioral medicine faculty work closely with residents to process their concerns and select portions of tape to provide a shared learning experience at the resident conference.7
Our team continues to learn from both patients and residents during each home-visit presentation. Future goals for this program involve making assessments about the long-term educational value of the Hospital to Home experience, including measuring the attitudes and participation in discharge planning of residents who have completed the internship-year program, once they have reached their second and third years of training, and developing a standard approach to educating and evaluating residents' understanding of functional assessment, medication management, and durable medical equipment.
Appreciating the complexity of thoughtful discharge planning decisions for an older patient population and developing the clinical skills needed by physicians-in-training to facilitate such a transition can be difficult to teach or to learn without an opportunity to experience and critically analyze the results. Harnessing the impact of the home visit on video and sharing the experience with a group of residents and faculty allow opportunities for open discussion of discharge planning conceptualization, options, and outcomes. This process also sensitizes residents to the challenges and unique issues that they encounter as providers and that older persons confront as consumers of medical care.