Orlando Sentinel Front Page Story Recognizes the SeniorBridge for MetCare program as an innovative and effective approach to improving care and reducing hospitalizations and cost of care of chronically ill seniors

 Orlando Sentinel - November 12, 2010 - Nurse house calls may be future of medicine
By Linda Shrieves, Orlando Sentinel

When nurse Sherry Dvorak makes a house call, there's more than just medicine involved.

While chatting and socializing with patients over coffee and cream puffs, Dvorak checks her patients' blood pressure and listens to their lungs. But she also listens to their problems. If they call her and need a ride to the doctor's office, she picks them up. If they're having a bad reaction to medication, she rushes over. If they cannot get through to the pharmacy, she makes the call.

"She really lifts my spirits," said patient Joan Love, 77, of Ormond Beach. "She has been a real godsend."

Dvorak, a home-health nurse, is part of a pilot program aimed at keeping seniors - particularly those who are chronically ill - from repeatedly being hospitalized. The program is designed to save Medicare money while improving the health of vulnerable seniors.

The pilot program Dvorak works on is what Medicare calls a "medical home," in which a primary-care doctor coordinates a patient's care with the help of non-medical staff. And under health-care overhaul, it may be the future of medicine.

Launched in August, the pilot is being run by Metcare, a doctors' group that provides primary care to Medicare patients in Volusia County, and SeniorBridge, a home health-care agency. Metcare selected patients for the program based on the number of times they had been in and out of the hospital. Patients were referred to the program by Metcare's primary-care doctors and hospitalists.

Many have no relatives nearby or they have chronic conditions that require frequent doctors' visits. And if they've been recently discharged from the hospital, many go home confused about their medications and what they need to do.

Recent research published in the New England Journal of Medicine found that one in five seniors is rehospitalized within 30 days of being discharged from a hospital.

Metcare's new program is designed to prevent that. Instead, patients can call an on-call nurse 24 hours a day. And a nurse or social worker visits them at least once a week.

In Daytona, the team of nurses and social workers already has prevented several emergency-room visits. For instance, one patient with COPD (chronic obstructive pulmonary disease) called his home health nurse on a Saturday, complaining that he was very short of breath. She drove to his home in 20 minutes and found him in the middle of a panic attack. She gave him his anti-anxiety medication, then sat with him and calmed him down. Once it had passed, she contacted the primary-care doctor's office to let them know what was going on.

For doctors, this extra layer of care is reassuring. "I see patients in the office for 15 or 20 minutes, maybe 30 at the most," said Dr. Jose Guethon of Metcare. "But someone who is able to follow them at home can get a much broader picture of what's going on from a social, economic, physical, nutritional perspective - all of which affect their care."

Sometimes patients' needs aren't medical. Some need a ride to a doctor's appointment. Others need help sorting through medical bills. And some call because they're lonely.

"A lot of the needs of these clients are social," said Patricia Canney, director of clinical operations for the care management division. "What do you do if you have a senior who doesn't have any food in the house? If we can assist in getting funds or going to urban ministries and picking up groceries, then we do that. Those are social needs, not medical needs, but sometimes the social needs are just as important."

When Metcare's team approached patient Carolyn Austin about participating in the pilot program, they quickly began tackling her problems. Social worker Mike Ward arranged for a new wheelchair, because her old one had a torn armrest that was cutting her skin and leading to infections. Because her severe rheumatoid arthritis makes it difficult to open pill bottles, Dvorak asked the pharmacy to provide flip-top pill bottles.

After recovering from hip-replacement surgery, Austin couldn't get in and out of her home. So Ward put her name on a waiting list for a county organization that would install a ramp. Recently, the ramp was installed.

Dvorak has "been a big help to me," said Austin, 73, of Daytona Beach. "I hope this works out because it's a wonderful program."

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