Dr. Soriano has received an honorarium (less than $10,000) from Finger Lakes Region Geriatric Education Center.
Rheumatologists on the road: A subspecialist's role in caring for the homebound
Version of Record online: 27 SEP 2011
Copyright © 2011 by the American College of Rheumatology
Arthritis Care & Research
Volume 63, Issue 10, pages 1482–1485, October 2011
How to Cite
Jain, R., Dasari, S., Soriano, T., DeCherrie, L. and Kerr, L. D. (2011), Rheumatologists on the road: A subspecialist's role in caring for the homebound. Arthritis Care Res, 63: 1482–1485. doi: 10.1002/acr.20539
- Issue online: 27 SEP 2011
- Version of Record online: 27 SEP 2011
- Accepted manuscript online: 7 JUL 2011 02:11PM EST
- Manuscript Accepted: 21 JUN 2011
- Manuscript Received: 10 APR 2011
By 2030, the number of permanently homebound individuals in the US will increase by 50% to reach 2 million. However, no medicine subspecialty consult services exist for this rising subset of the population. This pilot program establishes a rheumatology consult service for the Mount Sinai Visiting Doctors, the largest primary care academic home visit program in the nation serving more than 1,000 patients in New York City. Our service addresses the unmet need for homebound patients with rheumatic diseases, and secondarily provides an educational opportunity for trainees in community-based rheumatology.
Using an electronic medical record, home-based primary care physicians sent consult requests to the Rheumatology Division. Initial assessments were made using the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire.
Over 12 months, 57 home visits were made: 31 new consults and 26 followup visits. Reasons for referral included medical management of a known connective tissue disease, question of inflammatory arthritis, and procedures. The demographics for new consults were as follows: 94% women, 45% Hispanic, and 80% between ages 60 and 101 years. Thirty-nine percent of patients had rheumatoid arthritis. Treatment interventions included addition of a disease-modifying antirheumatic drug in 11 patients, 11 procedures, nonpharmacologic management in 8 patients, and a change in the dose of the existing medication in 5 patients. At the initial evaluation, the average RAPID3 scores for patients reflected high severity of disease.
The number of consults and the severity of disease seen highlight the importance of a rheumatologist's role in the community, especially because the number of homebound patients will dramatically increase in the future.
In the next 20 years, the number of permanently homebound individuals in the US will increase by 50% to reach 2 million. In 2030, 20% of the population will be older than 65 years of age (1). These statistics demonstrate the growing need for medical care for this subset of the US population, for both primary care medicine and medicine subspecialists. Home-based primary care (HBPC) models exist throughout the nation, but have been relatively slow to develop. We know from experience that the inadequacy of these programs has been associated with increased emergency room visits, hospitalizations, caregiver burn out, and most importantly, patient suffering (2–6). To our knowledge, there are no established medicine subspecialist consult services reported in the literature for this rising subset of the population until this recent initiative was started.
The basis for this pilot study stemmed from a successful model of HBPC: in 1995, 3 Mount Sinai Medical Center medicine residents established the Mount Sinai Visiting Doctors program to provide primary care to the homebound in East Harlem, New York. Today, it has grown to be the largest academic home visit program in the US, serving more than 1,000 patients throughout New York City (1, 2). Despite its success in the realm of primary care, however, the Mount Sinai Visiting Doctors have only had intermittent psychiatric consult services, and no other input from any medicine subspecialists. The Visiting Doctors registry documents that 91% of these patients need help with 1 or more activities of daily living (ADLs), and 98% with independent ADLs (1). Much of this disability arises from musculoskeletal problems that rheumatologists can treat.
Therefore, our purpose in establishing a rheumatology home visit program was to address a currently unmet need for homebound individuals in the community by providing consultations in the treatment, management, or diagnoses of rheumatic diseases. By meeting these needs, we hoped to improve the quality of life, to decrease pain and suffering, and to improve mobility of this population through targeted treatments. Secondarily, this initiative also provides education for fellows, residents, and medical students in a unique learning environment from patients in the community. These trainees were given an insight into community-based rheumatology by encountering patients with late-stage debilitating disease.
Significance & Innovations
In the next 20 years, the number of permanently homebound individuals in the US will increase by 50% to reach 2 million. However, the culture of medicine subspecialists providing care for patients in their homes has not followed the few primary care home-based models that exist in the nation.
Many individuals are homebound secondary to musculoskeletal incapacities and diseases that rheumatologists treat, and primary care physicians may not be equipped for caring for this aspect of their disability.
This new initiative reveals the extent and high severity of diseases seen in this hidden subset of the population, and demonstrates a rheumatologist's important role in caring for these patients.
To our knowledge, this is the first reported study of medicine subspecialists providing care for the homebound population, and the first reported educational endeavor in community rheumatology in a fellowship program.
Materials and Methods
HBPC physicians sent consult requests to the Rheumatology Division via an electronic medical record. Rheumatology fellows, accompanied by either internal medicine residents or medical students, saw 6 patients per month on average in their homes. Since this was a pilot study incorporating community home visits into a fellowship curriculum apart from regular outpatient clinics and inpatient responsibilities, 2 or 3 patients were seen in a half day twice a month. Patients were seen throughout Manhattan. Demographics, reason for consult, disease activity on initial evaluation, and treatment intervention were recorded for each patient. Attendings precepted via telemedicine and photos, and saw patients in the home for complicated cases. For each new consult, patients seen were evaluated for appropriate followup. The Routine Assessment for Patient Index Data 3 (RAPID3) score was used as an objective measure of clinical disease activity (7). The RAPID3 score incorporates 3 subsets of the Multidimensional Health Assessment Questionnaire: physical function, patient global assessment for pain, and patient global assessment for overall health in a tallied score. A score greater than 13 reflects high severity, 7–12 reflects moderate severity, and 4–6 reflects low severity of disease.
Over 12 months, 57 home visits were made: 31 as new consults and 26 followup visits. The most common reasons for referral included: 1) medical management of known arthritis/connective tissue disease, 2) question of inflammatory arthritis, 3) question of disease activity, and 4) procedures: intraarticular injections, arthrocentesis, and bursa drainage. The demographics of new patients seen were as follows: 94% were women, 45% were Hispanic, and 80% were between ages 60 and 101 years. Twenty-six patients lived alone or with a home health aide and 5 patients lived with other family members.
The following diseases were seen, either as having the diagnosis prior to our evaluation or given a diagnosis after our assessment: 39% percent of patients had rheumatoid arthritis (RA; all had established diagnoses), 30% of patients seen also had osteoarthritis (as a single disease or concomitant with another rheumatic diagnosis; ∼30% of these cases were given this diagnosis after our encounter), and 19% had crystalline arthropathies (∼50% of these cases were given this diagnosis after our encounter). One patient each having an established diagnosis of psoriatic arthritis, progressive systemic sclerosis, and polymyositis were also seen.
Treatment interventions included the following: addition of a disease-modifying antirheumatic drug (DMARD) in 11 patients, 11 procedures, counseling in 8 patients, and a change in the dose of the existing medication in 5 patients. At the initial evaluation, the average RAPID3 score for patients with RA was 22.4 and for patients with crystalline arthropathy was 19.3, reflecting high severity of disease. One patient with psoriatic arthritis on initial evaluation had a RAPID3 score of 21 (high severity); after intervention, the score was 11 (moderate severity). One patient with diffuse scleroderma had a RAPID3 score of 20.3 (high severity).
The following is representative of the cases encountered in consultation.
We were asked to see a 77-year-old woman with a medical history significant for atrial fibrillation, hypertension, and diabetes mellitus that were well managed by her HBPC physician, who had been seeing her for many years. Although she had seropositive erosive RA, she was not being treated with DMARDs because she was homebound. On initial examination, she had more than 12 swollen and tender joints as well as contractures. Her pain was being palliated by opiates, and she was afraid of taking prednisone, given her history of diabetes mellitus. We recommended methotrexate and a short course of prednisone. Initially, the patient refused to take these medications. However, with continued followup, not only did we gain her trust but she also became more debilitated and now bedbound. She finally agreed to take methotrexate/steroids and her synovitis and mobility have improved.
A 37-year-old woman with a history of rapidly progressing diffuse scleroderma that began at age 35 years was seen in her home. She was not only homebound, but also bedbound secondary to severe skin thickening and contractures. The patient had severe skin manifestations without internal organ derangements. We started her on D-penicillamine. Per her primary care provider and caretaker, the patient had been experiencing anterior shoulder pain and upper back pain for some time that was thought to be musculoskeletal in origin. However, when we saw her, our concern was of a possible pulmonary versus cardiac cause of her pain. She was admitted to the hospital and we were not surprised to learn that she had large pulmonary embolisms. She is currently being anticoagulated.
A 38-year-old woman with morbid obesity, schizophrenia, and psoriatic arthritis was initially seen in consultation by a rheumatologist as an outpatient and was started on methotrexate for her active psoriatic arthritis. She was then lost to followup because she stopped coming to her appointments. The patient was homebound primarily by her psychiatric illness and obesity. When she was seen in her home, the patient was experiencing dactylitis, as well as pain and swelling of her knees, wrists, and ankles. We reinitiated methotrexate therapy as well as a brief course of steroids, and her synovitis has improved.
The number of permanently homebound patients will increase in the next 20 years. As these statistics show, there will be a greater need for providing care to patients in their homes. Not only will primary care providers (PCPs) be especially important in this role, but also subspecialists in providing a multidisciplinary approach for comprehensive care. Although there are PCPs that make house calls, there has not been an established culture of medicine subspecialists that commonly incorporate home visits into their practices in the US. With the statistics outlined above, and the growing emphasis on the patient-care model in the home, there will be a paradigm shift in the way subspecialists may practice medicine in the future (3).
There are few examples, however, of other specialists that provide care to the homebound. In the UK, there is an example of a rheumatology clinical nurse service that provides primarily emotional, psychological, and social support to patients in the community (8). The Mental Health Outreach Program for the Homebound Elderly at Columbia-Presbyterian Medical Center Department of Psychiatry in New York City is a good example of a rare multidisciplinary team for homebound elderly adults with psychiatric illness. The team is comprised of a psychiatrist, an internist, social workers, nurses, health aides, and a physical therapist. They provide a comprehensive service of initial assessment, acute intervention, case management, and ongoing treatment (9).
There are also cases in the literature of mobile dentists who make home visits, primarily for the elderly population in the New York City, Boston, and rural areas. Again, there are no established medicine subspecialists that commonly make house calls.
Therefore, this pilot program highlights the role of a rheumatologist in caring for the homebound. Much of the existing data regarding the extent of musculoskeletal disease in the US come from rural settings (10). However, as this pilot study shows, urban areas in this country will also have an increased incidence of homebound patients with rheumatic diseases. An important idea to remember is that patients are homebound not from their underlying diabetes mellitus, hypertension, or renal insufficiency, but often their musculoskeletal incapacities, psychiatric illnesses, and social environment keep these patients at home. Of all subspecialists, visiting rheumatologists are especially needed for this reason. Often, the skills that rheumatologists use are portable; they rely heavily on clinical history, physical examination, and procedures, all of which are transportable. For example, one can easily carry needles, syringes, steroids, and lidocaine for intraarticular injections, arthrocenteses, bursitis injections, or bursa drainages. Visiting nurse services can be used to help with blood draws for laboratory work and injectable medication administration, and portable home radiograph service companies can be employed for imaging.
The RAPID3 score was used to provide an objective clinical assessment of a patient's disease activity across different rheumatic diseases (7). The average RAPID3 score on initial evaluation was greater than 20 in this population, reaffirming the great need for treatment and intervention in this hidden subset of the population. In the future, comparisons of RAPID3 scores before and after interventions will be an important aspect to study.
Educational opportunities to teach fellows, residents, and medical students about rheumatic diseases that are often at later stages than are seen in the clinic setting, as well as performing procedures, is an important part of this initiative. Targeted pain control has also been a significant part of this program, for example, giving a patient with RA a brief course of prednisone instead of narcotics for flares when synovitis cannot easily be assessed by a PCP.
During the course of the year, several barriers were encountered that are not always apparent in the clinic setting. Patients were resistant to medications initially, and it often took time to establish a trusting relationship with a new physician caring for patients in such an intimate setting as their own home. Finally, since homebound patients tend to have much lower functional status compared with those patients that are able to make it to outpatient appointments, goals for improvement were tempered and focused on quality of life and pain control.
Fifty-seven home visits were made in this study period, and since the end of this pilot program, there have been an increasing number of consults. The fellowship curriculum will possibly allow more days to make home visits in the future, as there is currently a waitlist for new patients to be seen in their homes. However, this will have to be balanced with a busy inpatient consult service as well as outpatient clinic days. Also, given the nature of seeing patients in the home, travel times from one place to another decrease the number of patients that can be seen in one day. It is important to remember that the seemingly small number of patients seen in their homes in this pilot study does not devalue the experience of each patient visit. Furthermore, it highlights a commitment to community service that is not commonly incorporated into an academic fellowship program. Evaluations by fellows, students, and residents after patient encounters have been positively received.
In terms of the cost assessment of a home visit by a consultant, Medicare, Medicaid, or commercial insurance for the house call and procedures can be billed and the reimbursement is comparable to a regular office visit. Home visits can be a viable option in that they are reimbursable by insurances, reach an underserved and more severely ill population, and can save the larger health system costs by preventing avoidable emergency room visits, hospitalizations, and ambulance transport to an office setting. The costs to the practitioner would be travel and time, but these can be mitigated by scheduling visits close by or designating time in an office practice setting to group as many visits together as possible.
In conclusion, the ongoing rising number of consults, the nature of consults, and the extent of disease on the initial evaluation of these homebound individuals highlights the importance of a subspecialist role in patient visits in the community, and especially by rheumatologists. This initiative underscores the presence of a hidden population with unmet needs and defines our role in patient advocacy consistent with our goals and beliefs as physicians and as rheumatologists.
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Jain had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study conception and design. Jain, Soriano, DeCherrie, Kerr.
Acquisition of data. Jain, Dasari.
Analysis and interpretation of data. Jain, Kerr.