No place like home: teaching home visits
Sondra Zabar, Section of Primary Care, New York University School of Medicine, 550 First Avenue, BCD D401, New York, New York 10016, USA. Tel: 00 1 212 263 8895; Fax: 00 1 212 263 8234; E-mail: Sondra.email@example.com
Context and setting
As the baby boomer generation ages, the number of people aged 65 years and over will exceed 40 million by the year 2010. Given this demographic change, it is important to equip primary care doctors with the skills and knowledge they need to carry out and document clinically meaningful patient home assessments.
Why the idea was necessary
Primary care doctors need to be prepared to care for elderly patients who are susceptible to injury and health hazards inside their home. Home safety assessments that identify risk may help prevent morbidity such as falls, poor nutrition and medication errors. Although most primary care internal medicine (PCIM) residents hold positive attitudes towards patient home visits, they view them as impractical in practice. For this reason, we developed and evaluated an experiential curriculum for PCIM residents designed to improve their comfort and confidence in using the skills needed to successfully analyse and document effective home visits.
What was done
Over a 9-month period, each resident joined a group of four to six peers and a faculty member on three home visits to different patients selected from a resident’s panel. Visits were followed by a structured debriefing. Residents completed a five-station objective structured clinical examination (OSCE) and an 11-item pre- and post-curriculum questionnaire. The OSCE tested residents’ skills in: (i) determining goals for a home visit (chart review); (ii) asking the patient’s permission to visit (standardised patient [SP] interaction); (iii) assessing the home for safety risks (photographic home tour); (iv) negotiating a safety plan with the patient (SP interaction), and (v) documenting the visit (writing a note). The SP completed a behaviourally anchored checklist that rated residents’ communication and case-specific skills, summarised as the percentage of items ‘well done’. The contents of notes were analysed and coded by two independent raters.
Evaluation of results and impact
A total of 38 residents visited 17 patients utilising 51 hours of faculty time. The OSCE (n = 38 pre-test, n = 21 post-test; 21 matched pairs) found residents’ communication skills had improved (scores pre = 60%, post = 82%; P = 0.001); residents were also better at making specific home safety recommendations and checking the patient’s willingness to comply (pre = 60%, post = 90%; P = 0.003). Post-curriculum, residents documented more items to evaluate in a home visit (pre = 28%, post = 36%; P = 0.004), as well as more safety hazards (e.g. a loose rug in the hallway) and more correct recommendations to prevent physical injury in the home (pre = 54%, post = 66%; P < 0.001). Compared with prior to taking the programme (n = 27), residents after the curriculum (n = 17) felt more comfortable carrying out a comprehensive home visit (pre = 2.2, post = 3.7 on a 5-point scale; P < 0.001), more confident about assessing their patients’ physical safety at home (pre = 2.3, post = 4.0; P < 0.001) and less concerned about the time investment involved in making home visits. In all 17 visits, new and important clinical information was uncovered. It appears a focused, patient-centred experiential curriculum that improved residents’ skills as well as their confidence and comfort in conducting patient home visits, all of which should help primary care doctors to make home visits clinically meaningful, particularly in terms of preventing future physical injuries in patients at risk.