Article

The Mount Sinai (New York) Visiting Doctors Program: Meeting the Needs of the Urban Homebound Population

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Abstract

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center's Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24–hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, local physicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical, nursing, and social work trainees interested in home-based primary care.

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... This article describes the development of a psychiatric consultative service within Mount Sinai Visiting Doctors Program (MSVD), a large academic home based primary care program in New York City (Ornstein, Hernandez, DeCherrie, & Soriano, 2011). We describe 1) our assessment of the psychiatric needs of this population, 2) the psychiatric consultation service intervention that was developed in response to those needs, and 3) the results of the intervention and its impact on patient care in our practice. ...
... Mount Sinai Visiting Doctors Program (MSVD) is the largest academic HBPC in the United States and serves more than 1000 homebound individuals in Manhattan annually (Ornstein, et al., 2011). MSVD physicians and nurse practitioners provide routine and urgent primary medical care, in-home palliative and end-of-life care, and 24-hour physician access to our homebound patients. ...
... The principal requirement for program eligibility is the patient's inability to routinely visit a doctor's office because of functional or cognitive impairment. MSVD accepts private insurances, Medicare, and Medicaid (Ornstein, et al., 2011). ...
The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.
... Mount Sinai Visiting Doctors (MSVD) is the largest academic home-based primary care program in the United States. Described elsewhere in detail (28,29), the MSVD team of physicians, social workers, nurse practitioners, and nurses collaborate with community nursing agencies to provide multidisciplinary primary care to more than 1,000 homebound individuals in Manhattan annually (30,31). Any patient over the age of 18 living in Manhattan who meets the Medicare homebound definition (able to leave home only with great difficulty and for absences that are infrequent or of short duration) is eligible to enroll in MSVD. ...
... Symptom burden for pain, anxiety, depression, and tiredness in homebound patients has been successfully managed and decreased with home based primary care (HBPC) programs (45). Fortunately, the number of home based primary care (HBPC) programs that are able to provide comprehensive treatment of chronic conditions and symptoms for the homebound is growing (23,26,29,46). These programs have already been shown to improve the health of the homebound population while decreasing healthcare spending (47)(48)(49)(50)(51)(52). ...
Article
Context: Homebound adults experience significant symptom burden. Objectives: To examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death. Methods: Three hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale, ESAS), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death. Results: Of the study sample, 43% had severe symptom burden (i.e., ESAS score ≥6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P<0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P<0.01), higher prevalence of depression (43.4% vs. 12.0%, P<0.01), lower prevalence of dementia (34.3% vs. 60.6%, P<0.01), and utilized fewer hours of home health services (86.2 vs. 110.4 hrs/wk, P<0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio=1.51, 95% confidence interval 1.06-2.15) in adjusted models, but had no association with time to nursing home placement or death. Conclusion: The homebound with severe symptom burden represent a unique patient cohort who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population.
... There are approximately 2 million older adults in the U.S. who are homebound and have difficulty accessing traditional medical care. 20 The Mount Sinai Visiting Doctors Program (MSVD), which serves more than 1,500 homebound patients in Manhattan, 85% of whom are over 70 years of age, 21,22 is the largest academic HBPC program in the United States. MSVD has an interdisciplinary staff of physicians, NPs, registered nurses (RNs), social workers (SWs), and administrative assistants who provide primary care, palliative care, and social services to the urban homebound. ...
... MSVD patients have access to 24hour physician telephone coverage. 22 PCPs are the main point of contact for their patients, while RNs assist with triage and SWs see all patients on admission and as necessary by referral afterwards. ...
Article
By providing more frequent provider visits, prompt responses to acute issues, and care coordination, nurse practitioner (NP) co-management has been beneficial for the care of chronically ill older adults. This paper describes the homebound patients with high symptom burden and healthcare utilization who were referred to an NP co-management intervention and outlines key features of the intervention. We compared demographic, clinical, and healthcare utilization data of patients referred for NP co-management within a large home-based primary care (HBPC) program (n = 87) to patients in the HBPC program not referred for co-management (n = 1027). A physician survey found recurrent hospitalizations to be the top reason for co-management referral and a focus group with nurses and social workers noted that co-management patients are typically those with active medical issues more so than psychosocial needs. Co-management patients are younger than non-co-management patients (72.31 vs. 80.30 years old, P < 0.001), with a higher mean Charlson comorbidity score (3.53 vs. 2.47, P = 0.0001). They have higher baseline annual hospitalization rates (2.27 vs. 0.61, P = 0.0005) and total annual home visit rates (13.1 vs. 6.60, P = 0.0001). NP co-management can be utilized in HBPC to provide intensive medical management to high-risk homebound patients.
... Many MSVD patients have dementia and receive daily support from both paid and family caregivers. 21 From the first diagnosed NYC COVID-19 case on March 1, 2020 infections spread rapidly through the city, with cascading effects on the Mount Sinai system. [See Figure 1] MSVD stopped enrolling new patients and converted primarily to Legend: From the identification of the first NYC COVID-19 case on March 1, 2020, the disease spread rapidly as state and local leaders implemented emergency policy measures to slow transmission and increase health system capacity (events noted in black). ...
Article
Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC's multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.
... For example, despite the advanced age of the population and the fact that all respondents had difficulty accessing usual primary care as a criterion for receipt of the HV service, less than half (41.3%) identified "old age" (frailty) as a serious condition. Similarly, the frequency of self-reported heart and lung disease ( Likewise, only one in five respondents (20.7%) reported "memory problems or Alzheimer's" as a serious condition, which is substantially lower than the dementia prevalence rates ranging from 33.8 per cent to 64.5 per cent reported in studies on similar populations derived from clinical data (Beck et al., 2009;Chang et al., 2009;Ornstein, Hernandez, DeCherrie, & Soriano, 2011;Rosenberg, 2012;Wajnberg et al., 2010). Self-reported dementia prevalence may in part be explained by our study exclusion criteria that screened out those with advanced dementia; however, combined with the lower self-reported prevalence rate of other chronic conditions, selection bias of respondents is unlikely to fully explain this under-reporting of dementia. ...
Article
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RÉSUMÉ Pour notre sondage, nous avons utilisé une méthodologie mixte basée sur le Web (How’s Your Health – Frail) pour examiner la santé des adultes fragiles (78% âgés de 80 ans et plus) inscrits à un programme de soins primaires à domicile à Vancouver, au Canada. Soixante pour cent des répondants admissibles ont participé, représentant plus d’un quart (92/350, 26,2%) de tous les individus qui reçoivent le service. Malgré des niveaux élevés de co-morbidité et de dépendance fonctionnelle, 50% ont jugé leur santé aussi bonne, très bonne ou excellente. Les ratios de cotes ajustés pour l’auto-évaluation de sa santé positive étaient de 7,50, 95 pour cent d’intervalle de confiance (IC) [1,09, 51,81] et 4,85, 95% CI [1,02, 22,95] pour l’absence de symptômes gênants et le pouvoir de parler à la famille ou amis, respectivement. Des réponses narratives aux questions sur la fin de vie et la vie avec une maladie sont également décrites. Les résultats suggèrent que l’accent mis sur la gestion des symptômes, et le soutien des contacts sociaux, peut améliorer la santé des personnes âgées fragiles.
... [XX] Visiting Doctors Program (MSVD) is a home based primary care practice in [XX] that provides care to an ethnically and socioeconomically diverse homebound population (K. Ornstein, Hernandez, DeCherrie, & Soriano, 2011;Smith et al., 2006). What started as a small pilot project in [XX] in 1995 has grown into the largest academic home based primary care program in the U.S. and currently cares for more than 1000 homebound individuals across [XX] each year. ...
Article
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The growing homebound population has many complex biomedical and psychosocial needs and requires a team-based approach to care (Smith, Ornstein, Soriano, Muller, & Boal, 2006). The Mount Sinai Visiting Doctors Program (MSVD), a large interdisciplinary home-based primary care program in New York City, has a vibrant social work program that is integrated into the routine care of homebound patients. We describe the assessment process used by MSVD social workers, highlight examples of successful social work care, and discuss why social workers' individualized care plans are essential for keeping patients with chronic illness living safely in the community. Despite barriers to widespread implementation, such social work involvement within similar home-based clinical programs is essential in the interdisciplinary care of our most needy patients.
... Described in detail elsewhere 16,17 , the Mount Sinai Visiting Doctors program was founded in 1995 and employs an interdisciplinary team to provide primary care for patients in their homes. To be enrolled in the program, patients must meet the Medicare definition of homebound: able to leave home only with great difficulty and for absences that are infrequent or of short duration 18 . ...
Article
Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.
... Patients are enrolled regardless of insurance status, comorbidities, or cognitive status. 23 Design Patients were administered a baseline ESAS as part of their routine clinical care on an initial visit by their primary care provider (PCP) to assess current symptom burden. The ESAS was completed either by the patient alone, caregiver alone, or the patient assisted by the caregiver as determined by the PCP's assessment of the patient's ability. ...
Article
Background: Increasing numbers of patients are living with multiple, chronic medical conditions and functional impairments that leave them homebound. Home-based primary and palliative care (HBPC) programs provide access to health care services for this vulnerable population. Homebound patients have high symptom burden upon program enrollment. Yet little is known as to how individual symptoms are managed at home, especially over longer time periods. Objectives: The purpose of this study was to determine whether high symptom burden decreases following HBPC enrollment. Methods: All patients newly enrolled in an HBPC program who reported at least one symptom on the Edmonton Symptom Assessment Scale (ESAS) were eligible for telephone ESAS follow-up. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow-up care, interdisciplinary care management including social work, and urgent in-home care as necessary. Multivariate linear mixed models with repeated measures were used to assess the impact of HBPC on pain, depression, anxiety, tiredness, and loss of appetite among patients with moderate to severe symptom levels at baseline. Results: One hundred forty patients were followed. Patient pain, anxiety, depression, and tiredness significantly decreased following intervention with symptom reductions seen at 3 weeks and maintained at 12 weeks. (p<0.01) Loss of appetite trended toward an overall significant decrease and showed significant reductions at 12 week follow-up. Conclusion: In a chronically ill population of urban homebound, patient symptoms can be successfully managed in the home. Future work should continue to explore symptom assessment and management over time for the chronically ill homebound.
... Using a combination of measurement tools to assess caregiver burden, Ornstein et al demonstrated that the MSVD program led to a decrease in unmet needs and in caregiver burden. 19,20 Caregiver burnout can be assessed using the Caregiver Burden Inventory, a validated 24-item questionnaire. 21 ...
Chapter
Home-based health care has grown over the past years and may continue to grow, especially if payment models change from fee-for-service to Accountable Care Organizations as care will be organized to reduce hospitalizations, emergency room visits, and nursing home placements for patients with complex medical needs. Home care includes personal care services and professional services, the latter of which can include the provision of care from physicians; advance practice practitioners; nurses; physical, speech, and occupational therapist; and social workers. Programs in the community can increase support for patients at home. Home-based medical care provides professional clinical services that include single consultative assessments, disease-specific care, primary care, and palliative care. Quality metrics have been established for home-based primary and palliative care.
Article
Objectives: Given the high needs and costs associated with the care of children with medical complexity (CMC), innovative models of care are needed. Home-visiting care models are effective in subpopulations of pediatrics and medically complex adults, but there is no literature on this model for CMC. We describe the development and outcomes of a multidisciplinary program that provides comprehensive home-based primary care for CMC. Methods: Medical records from our institution were reviewed for patients enrolled in our program from July 2013 through March 2019. Demographics, clinical characteristics, and health care use were collected. We compared the differences in pre- and postprogram enrollment health care use using Wilcoxon signed rank test. We applied Cox proportional hazard models to examine the association between the time-dependent postenrollment health care use and numbers of home visits. We collected total claims data for a subset of our patients to examine total costs of care. Results: We reviewed data collected from 121 patients. With our findings, we demonstrate that enrollment in our program is associated with reductions in average length of stay. More home visits were associated with decreased emergency department visits and hospitalizations. We also observed in patients with available cost data that total costs of care decreased after enrollment into the program. Conclusions: Our model has the potential to improve health outcomes and be financially sustainable by providing home-based primary care to CMC.
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Nurse practitioner (NP) comanagement involves an NP and physician sharing responsibility for the care of a patient. This study evaluates the impact of NP comanagement for clinically complex patients in a home-based primary care program on hospitalizations, 30-day hospital readmissions, and provider satisfaction. We compared preenrollment and postenrollment hospitalization and 30-day readmission rates of home-bound patients active in the Nurse Practitioner Co-Management Program within the Mount Sinai Visiting Doctors Program (MSVD) (n = 87) between January 1, 2012, and July 1, 2013. Data were collected from electronic medical records. An anonymous online survey was administered to all physicians active in the MSVD in July 2013 (n = 13).After enrollment in comanagement, patients have lower annual hospitalization rates (1.26 vs. 2.27, p = .005) and fewer patients have 30-day readmissions (5.8% vs. 17.2%, p = .004). Eight of 13 physicians feel "much" or "somewhat" less burned out by their work after implementation of comanagement. The high level of provider satisfaction and reductions in annual hospitalization and readmission rates among high-risk home-bound patients associated with NP comanagement may yield not only benefits for patients, caregivers, and providers but also cost savings for institutions.
Chapter
Children and adults with intellectual and developmental disabilities (IDD) often encounter a healthcare network that is limited in scope, size, and preparation.This system often results in lower quality of care and gaps in service owing substantially to the absence of appropriately trained providers.It is evident that the way in which we prepare physicians, psychologists and other practitioners needs greater attention. This chapter will address the many ways that health education programs can address disability issues: didactic instruction, community service encounters, clinical clerkships, standardized patient (SP) encounters, panel discussions with patients, advocates, and family members; in addition to home visits where students interact with individuals with disabilities outside of a healthcare setting.
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Background: One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions. Methods: Using 2011-2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community-dwelling Medicare beneficiaries. Homebound status (independent, semi-homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self-report. Transition probabilities across states were assessed using a multistate Markov model. Results: Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two-fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia. Discussion: Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home-based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care.
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The growing homebound population is heavily reliant on informal caregivers, who are increasingly burdened by their roles. This study describes informal caregivers of the homebound who remain caregivers at a 9-month follow-up and examines the impact of a home-based primary care (HBPC) program on caregiver burden and unmet needs using a prospective design with a pre—post intervention assessment. Informal caregivers of the urban homebound are similar to caregivers of other populations and have a broad range of unmet needs. The intervention described is the regular provision of multidisciplinary HBPC. Hundred fourteen caregivers of newly admitted patients complete a baseline interview. For the 56 caregivers who complete a 9-month follow-up interview, participation in HBPC is associated with a statistically significant decrease in overall caregiver burden. At 9 months, caregivers demonstrate an overall decrease in unmet needs, with a statistically significant decrease across two measured domains. These results suggest that the regular provision of multidisciplinary care in the home can mitigate the deleterious impact of informal caregiving.
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Home-based primary care for homebound seniors is complex, and practice constraints are unique. No quality-of-care standards exist. To identify process quality indicators that are essential to high-quality, home-based primary care. An expert development panel reviewed established and new quality indicators for applicability to home-based primary care. A separate national evaluation panel used a modified Delphi process to rate the validity and importance of the potential quality indicators. Two national panels whose members varied in practice type, location, and setting. The panels considered 260 quality indicators and endorsed 200 quality indicators that cover 23 geriatric conditions. Twenty-one (10.5%) quality indicators were newly created, 52 (26%) were modified, and 127 (63.5%) were unchanged. The quality indicators have decreased emphasis on interventions and have placed greater emphasis on quality of life. The quality indicator set may not apply to all homebound seniors and might be difficult to implement for a typical home-based primary care program. The quality indicator set provides a comprehensive home-based primary care quality framework and will allow for future comparative research. Provision of these evidence-based measures could improve patient quality of life and longevity.
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The Chelsea-Village Program (CVP) is a long-term home healthcare program for a largely isolated and impoverished frail homebound aged population, based at Saint Vincent's Hospital in New York City. Since January 1973, our CVP teams of physicians, nurses, and social workers have cared for the homebound aged over the long term. Twenty-seven years later, we have made 42,866 home visits to 2264 persons in lower Manhattan, an area of New York City housing a high concentration of older people. Our purpose is to help our patients remain in their own homes and community at the maximum possible level of personal control and to maintain the best attainable health. Additionally, the program is a valuable component of the Hospital's Primary Care Adult Medicine residency program. It also serves as a laboratory for the study of health problems faced by the homebound aged and the solutions to these problems. The program, a medical-social model, has required modest philanthropic investments, dedicated service by physicians, nurses, and social workers, and the support of a hospital with a strong charitable mission.The CVP experience has encouraged the creation of other long-term home healthcare programs across the country, including the Medicaid-supported Nursing Home Without Walls program that spans New York State. Thus, the CVP can be viewed as a model rather than an idiosyncratic non-replicable phenomenon. As such, the program has established that multidisciplinary healthcare teams, in collaboration with a teaching hospital, can provide long-term home health care to homebound older people in the local community. Moreover such a practice is mutually beneficial. J Am Geriatr Soc 48:1002-1011, 2000.
Article
The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost–benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.