“For me, these patients are all like my grandparents,” said Oates, who was close with his own.
Working with a group of social workers and nurse case managers to help people with issues that go beyond medical conditions is rewarding, he said.
Home visit teams might look for loose rugs or poor lighting that could cause a fall, and do what Swartz called the “refrigerator biopsy” to see if people are getting enough food.
Oates said he and colleagues also detect whether patients are safe in custody of their caregivers — he had several open protective services cases in mid-June — or if their drugs are taken by relatives or others in the home. And, he said, going over a patient’s drug regimen in the home, where they have their medications on hand, can help dispel confusion.
Oates sat recently in the second-floor bedroom of the Dorchester home where Ella Mitchell, 88, spends nearly all of her time. He told her she could stop one of the many medications she takes to treat a complicated list of conditions, including emphysema, history of pulmonary embolism, and a degenerative joint disease. But Mitchell wasn’t sure which one he meant.
She pulled her pill bottles from a desk drawer, and Oates went through them with her, identifying the blue pill she no longer needed.
“Medical care has been sort of provider-centric,” said Al Norman, executive director of Mass Home Care, a network of organizations that provide support for elderly people living at home. “The patient is at home. Where the provider lives is at the office. Historically, the provider has won out.”
Norman said he would welcome the expansion of services such as those Boston Medical Center provides, though he noted that physician assistants, nurses, or caseworkers, who are paid less, can play a big role in addressing medical needs in the home.
With home care, “you’re getting a window into the person’s life that you can’t possibly get in the office,” said Len Fishman, chief executive of Hebrew SeniorLife, a large senior care and housing provider in the Boston area. The group does not provide home-based primary care, though one of its Brookline housing facilities has a clinic on site. Fishman said he is encouraged by the Independence at Home pilot. But, he said, “if it works, then what?”
Swartz, whose organization is assisting with the pilot, said expanding the shared savings program beyond 10,000 patients nationally would require action by Congress. But if the federal agency shows that home care saves money over time, he said, more doctors may be inspired to get out of the office.
Chelsea Conaboy can be reached at firstname.lastname@example.org. Follow her on Twitter @cconaboy.