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Special Perspectives on Home en c:! Community Care Patricia P. Batty MY comments today are from the perspective ~ gained Is a primary care physician on the Home Medical Service (HMS) at Boston's University Hospital. Home Medical Service has provided home care in Boston for over 100 years, and begins with a comprehensive initial evaluation consisting of medical, social, and functional assessment, rou- tine laboratory studies, and electrocardiogram. FoDow-up care is man- aged by an HMS nurse-coordinator and consists of case management and home visits by physicians. Many of the patients are frail or sick elderly, with serious medical problems including dementia, congestive heart fail- ure, angina, chronic obstructive pulmonary disease, and malignancy. A1- though many have end-stage disease, every effort is made to maintain their quality of life and to continue their ability to live in the community, often with family members, for as long as possiblea major goal of many health care providers for He elderly. HEALTH SERVICES To provide care at home, it is essential to maintain He patient's functional status and coordinate the services of both family members and community agencies including nurses, home health aides, and homemak- ers. These arrangements are often precarious and can be easily disrupted, especially by acute hospitalization. A~nission to the hospital may result in immobility, a decrease in the capacity for activities of daily living, and a subsequent collapse of the support system as the padent assumes a "sick role." Family members may `'bum out," and in some cases hospitalization precipitates furler institutional care. In addition, old age increases risk 32

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SPECIAL PERSPECTIVES ON HOME AND COMMUNITY CARE 33 for iatrogenic complications of hospitalization that may prolong the stay and increase disability. Thus, a major goal of elderly patient management becomes the avoidance of unnecessary or optional hospitalization and, therefore, careful consideration of the risks and benefits of Me diagnostic and therapeutic modalities available there. Geriatnc services, however, are usually viewed as a source of inpatient admissions by many hospital administrators, to whom the "bot- tom line," despite diagnosis-related groups (DRGs), is still admissions (and timely discharges). Physicians, as the primary decision makers, may find themselves caught between conflicting responsibilities as hospital staff members and, more important, as patient care providers. For physicians in private practice, the Medicare reimbursement system clearly favors hospital care in an acute, procedure-oriented set- t~ng: primary care practitioners struggle to receive adequate reimburse- ment for lengthy home visits, assessment, family counseling, and mul- tidisciplinary teamwork, while their technologically oriented colleagues have no problem collecting for radiologic or laboratory studies, or inva- sive tests that may not only be uncomfortable but also pose risks to the patient. Unfortunately, such invasive tests (intravenous pyelograms, angi- ograms, endoscopy) may be ordered because they are available, with little thought given to the way in which the results (diagnoses or staging) win affect the treatment of the patient. This is particularly true of the frail, sick elderly, for whom treatment options may be limited because of patient (or family) wishes or the physiologic ability of the patient to tolerate therapy. Thus, although appropriate medical diagnosis and treatment may be important in the care of the sick elderly in the community, these cannot be the only goals of medical care. Maintenance of function and attention to psychosocial needs through coordinated care may be even more essen- tial to the patient's quality of life. Being at home has previously "pro- tected" the elderly from technological interventions; as those techniques become increasingly available in the home setting, it is critical that we better understand their risks and benefits to the patient. Health services in this country have focused recently on one com- ponent of the In angle of heals care reduction of costswith too little emphasis on access and quality. Quality is not synonymous with technol- ogy: more is not always better, and access is not synonymous with institutional admission. Consideration of the patient's needs and goals is critical to determine whether the care is of sufficient quality and whether I

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34 PATRICIA P. BARRY access has been provided to appropriate services. Issues of cost reduction need to be related to real cost and benefit. Frail elderly in the community have unmet needs. Policymakers must better understand the way that the health care system, by its structure and methods of reimbursement, fails to provide for these needs. Greater emphasis must be placed on the preservation of function and the provision of community services in locations other than institutions. The payment system must be shifted from its preferential emphasis on hospital-based acute care and technology to provision of adequate compensation for complex patient assessment and management, as well as those essential, although less technological, services provided in the community, includ- ing transportation and homemakers. EDUCATION The second critical component of our society's ability to provide appropriate medical care for the elderly is the manner in which we train our physicians. The growing trend in residency programs, such as family practice and internal medicine, emphasizes health care settings outside the hospital as wed as long-term care. The HMS is part of a required one- month community medicine rotation for senior medical students at Bos- ton University and for second-year internal medicine residents. Students rate the experience highly, as do the residents, many of whom comment that they are as impressed by the frailty of those patients kept at home as by those admitted. The HMS is often their first medical experience outside the acute hospital setting. Earlier this year, a panel discussion of home care at the American Medical Association considered changes in the education of physicians at all levels to include functional assessment, pain management, home care, disease prevention, discharge planning, understanding of community re- sources and the reimbursement system, and ethical issues. These areas are seldom covered in the medical school curnculum, during residency, or in continuing medical education courses despite their importance to the appropriate care of frail elderly patients. Medical education must continue its shift toward training physi- cians to provide care in noninstitutional community settings including the home. Physicians also need a better understanding of the value of their interventions in geriatric patient populations and He risks and benefits of their diagnostic and treatment modalities. The importance of comprehen- sive assessment and functional status must also be emphasized.

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SPECIAL PERSPECTIVES ON HOME AND COMMUNITY CARE 35 RESEARCH We cannot always predict the value of our technological ~nterven- tions in the elderly patient population, because most tests and treatments are developed and studied in younger patients with more clearly defined and isolated problems, better functional status, and less complex goals. More information must be obtained about the specific health care needs of the elderly. We recently completed a study on the HMS which demon- strated that elderly patients who refuse hospitalization often have negative feelings about the health care system in general and about hospices in particular; they tend to be less seriously ill than patients who accept hospital care; and they usually have appropriate outcomes in terms of location, health status, and function. How can we better identify those elderly for whom our interventions win be productive and provide a real benefit as opposed to a needless disturbance or a prolongation of He process of dying? Important research areas include better delineation of the unmet needs of this population and careful evaluation of programs designed to help them, including home care. The effect of health-care reimbursement policies on the overall quality of life and health of the elderly must be better understood. Appropriate clinical care requires research efforts to understand the effectiveness and appropriateness of diagnostic and thera- peutic interventions, especially those that pose important questions of risk versus benefit, such as invasive procedures and intensive care units. We especially need to understand the significance of age as a risk factor in predicting outcomes of technological interventions. We must not auto- matically impose upon or deny to the frail elderly those technological interventions developed for younger, healthier people without adequate evaluation. CONCLUSION Widespread application of available health resources to this spe- cial population has the potential for great benefit as weD as considerable harm. We must consider the special needs particular to this group, de- velop our policies and design our programs thoughtfully, educate our health care providers in He necessary knowledge and skills, and, finally, carefully and continuously evaluate our efforts toward providing He most appropriate care to meet the needs expressed by the patients themselves.