Annals of Long Term Care

It was mid-afternoon, and I was accompanying my Geriatrics preceptor on a home visit to a 95-year-old man with multiple medical conditions that included congestive heart failure (CHF). Aside from the three of us, the man’s granddaughter--who also lived with him--was there, and his 98-year-old wife was asleep in a bed in the corner. After a number of cardiac examinations and an ongoing debate about whether or not the man needed to be admitted for a CHF exacerbation, the elderly woman in the corner sat up and said, “Something is burning.” To which the daughter laughed and said, “I forgot to take the chicken out of the oven,” as she quickly left for the kitchen. I consider myself a very open-minded person, and in general I give the elderly a lot of respect and credit, but, I will admit, I was surprised that the most alert and responsive person in the room that day was a sleeping 98-year-old.

I attended a large medical school in Boston, well known for community outreach. For example, there is a student-run Outreach Van Project that serves the homeless of East Boston by living up to its motto of meeting people where they are. Similarly, we also have a rotation on the Geriatrics Home Care Service, which also represents the spirit of a physician as mobile caregiver. I had not given much thought to home visits prior to medical school; to me they were reminiscent of old-fashioned medical bags and “country docs.” On the other hand, I liked the idea of seeing patients in their homes—and felt it refreshing that this is one instance where we don’t make them come to us. My fellow classmates initially had mixed reactions to these experiences. In my group, it was too “slow-paced” for the future surgeons, too “remedial” for the future hospitalists, and not relevant enough for the future pediatricians. In addition, it turned out that no one in my group was planning on going into Geriatrics.

However, there were also few of us who saw this experience as invaluable, and so different from seeing a patient forced to come in to the less than comfortable confines of a clinic. It also seemed that by the end of the rotation, most students appreciated how clinically valuable it can be to visit patients in the home. By going to where your patient lives, you can see his or her environment and with that, so many factors affecting your patient’s health, much of it hidden when the patient comes to you.

For example, if the patient has difficulty walking, one can easily check for a guardrail in the bathroom. Some questions to ask include:

•For a patient with impaired vision: Is there a phone in the house with large numbers or Braille?
•Who helps the patient with paperwork (eg, phone, electric bills)?
•Can the patient sort out his or her own medications?
•Who takes care of picking up refills?

These and countless other questions can immediately be addressed during a home visit and would be much harder or impossible to answer in a clinic encounter. Much of this information involves preventive health, which may be the most effective positive intervention in an elderly patient’s life.

The majority of the patients we saw on the Geriatrics Home Service were either living alone, living with a younger family member, or living near a helping friend. The one commonality among these patients was that they did not quite need an assisted living facility or nursing home, but were not mobile enough to keep regular physician outpatient appointments. We saw a great deal of mentally sharp and highly functional patients, as well as some who appeared almost helpless and lived in shockingly poor and unsanitary conditions. One patient insisted on being examined on her front lawn, for fear if anyone was allowed inside her house it would be declared condemned and she would lose it. We also saw a blind man who lived alone and whose house was filthy, infested with cockroaches, and smelled strongly of stale urine.