Bringing Palliative Care into the Home

    In 1997, Veronica M. LoFaso, MD, MS, Director of Geriatric Medical Education in the Division of Geriatrics and Palliative Medicine at NewYork-Presbyterian/Weill Cornell Medical Center, and division Co-Chief Mark Lachs, MD, MPH, Irene and Rosy Psaty Distinguished Professor of Medicine, Weill Cornell Medicine, and Director of Geriatrics for the NewYork-Presbyterian Healthcare System, introduced a comeback of the house call concept focused on providing medical care to frail older adults who due to chronic disease, mobility impairment, or other physical and mental health issues are homebound or unable to travel to a doctor’s office.

    Through the EGL House Call Program, in memory of Clara Elizabeth Scheuermann, home visits once again found their rightful place in the delivery of health care to a very vulnerable population in need. It also created an important educational vehicle for medical students. The program’s growth was made possible by a transformative gift from The EGL Charitable Foundation that was directed by Evelyn Gruss Lipper, MD, Clinical Associate Professor Emerita of Pediatrics at Weill Cornell Medicine, and Daniella Lipper Coules, the Foundation’s Executive Director.

    “The house call is one of the finest traditions of medicine and all but a lost art,” said Dr. LoFaso at the time. “Instead of having to use the emergency room for primary care, our fragile patients can be served with dignity in the comfort of their homes.”

    Today, the EGL House Call Program has reached its 25-year milestone. It continues to grow in numbers of patients and services offered and now includes training for medical students, internal medicine residents, geriatric medicine fellows, and geriatric psychiatry fellows. Through the EGL House Call Program, medical trainees at all levels have the opportunity to gain real-life experiences outside the hospital setting. When they enter an elderly patient’s home, they can see firsthand the effects of health and illness on physical, social, emotional, and cognitive function.

    The core members of the program’s team are Karin E. Ouchida, MD, Program Director; Emily Finkelstein, MD; and Megan Lam, MSN, AGPCNP-BC, ACHPN, nurse practitioner. Each of these team members brings a steadfast commitment to geriatric medicine and expertise in the breadth of clinical and psychosocial issues impacting their patients.

    Dr. Karin Ouchida, Dr. Emily Finkelstein, and nurse practitioner Megan Lam

    “One of the things I love about working at Weill Cornell Medicine is that the institution values geriatrics and recognizes that the older population is unique and often the most medically and psychosocially complex,” says Dr. Ouchida. “Getting to know older adults and learning their life stories helps me to understand what is most important to them now so that we can best maximize their quality of life and how they want to live out the remainder of their lives.”

    “Being able to see our frail geriatric patients in their homes is a gift,” says Ms. Lam. “It allows us to provide continuity of care in a holistic way. You see how someone lives – whether they have food in their fridge, are they taking their medications, interactions between caregivers, display of family photos, books on shelves, or art on their walls. Seeing a patient in their home often allows the patient to open up and share life stories. We spend the time to know our patients, what brings them joy and dignity, and those conversations lead us to the more difficult conversations about what is an acceptable quality of life.”

    Palliative Care: An Important Complement

    Dr. Ian Kwok

    Most recently, with additional funding from the EGL Charitable Foundation, palliative medicine was integrated into the EGL House Call Program. This integration builds upon deep expertise in the Division of Geriatrics and Palliative Medicine, where co-chief Ronald D. Adelman, MD, directs adult Palliative Care at NewYork-Presbyterian/Weill Cornell. Ian B. Kwok, MD, Director of Community Outreach and Education, joins the EGL House Call Program core team, along with an additional nurse practitioner, to direct the expansion into palliative medicine. Dr. Kwok, who is fellowship trained in hospice and palliative medicine, has been named Director of the Palliative Care EGL House Call Program. He will work closely with Dr. Ouchida, Dr. Finkelstein, and nurse practitioner Megan Lam, as well as with Manali Saraiya, MD, who recently completed fellowships in both geriatrics and hospice and palliative medicine at NewYork-Presbyterian/Weill Cornell.

    “Knowing that so many of the needs of our patients are better met at home, it was a natural progression to add palliative medicine, especially since we are caring for geriatric patients who may have serious or life-limiting illness,” says Dr. Kwok. “The impetus was driven by understanding that there was a gap in meeting some of the needs of many of our patients who were receiving house calls. Many patients prefer to stay in their own home as long as possible, rather than undergoing frequent trips back and forth to the hospital because of worsening health. Unfortunately, we know that hospice is only available at the last six months of life. We also know that there are many permutations of what people really care most about that may not fit nicely into the hospice frame of mind. So, a big part of what we do in palliative care, in particular, is communication around serious illness and advance care planning.”

    By adding palliative care to the EGL House Call Program, we can provide expertise and further support for patients with a particularly high set of needs at times of either transition or related to serious illness when they really need extra attention.

    — Dr. Ian Kwok

    “The original hospice system was designed primarily for patients with cancer whose prognosis and course of the disease are relatively predictable,” explains Dr. Kwok. “When you expand that to patients diagnosed with comorbid serious illnesses – dementia, COPD, heart failure – the disease course is more difficult to predict. So oftentimes you have patients who are on the borderline and are enrolled in hospice but then their condition stabilizes. At each certification period, the hospice agency needs to reevaluate if the patient is still within that six-month prognosis and would still qualify. With new immunotherapies for cancer treatment, prognostication has become more difficult. That’s definitely good news in terms of having more opportunities for effective treatments for cancer patients, but also makes the hospice service picture a little bit more complicated.”

    “We began to see more and more of these situations arise, and recognized that the EGL House Call Program presented an opportunity to fill a gap in services,” continues Dr. Kwok. “By adding palliative care to the EGL House Call Program, we can provide expertise and further support for patients with a particularly high set of needs at times of either transition or related to serious illness when they really need extra attention. This is not necessarily built into the healthcare system as it currently stands.”

    The Case for Palliative Care

    “The palliative care service can assist a patient with cancer who does not qualify for hospice, wants to continue receiving treatment, but also wants to stay away from the hospital as much as possible,” says Dr. Kwok. “They may have a pain crisis at home or other symptoms in which case a physician or nurse practitioner from palliative care can go to the patient’s home to assess their symptoms and provide recommendations that conform with their personal choice,” says Dr. Kwok. “I believe this is a model of care that is much more targeted to the patient’s wants and needs and therefore much more patient-centered.”

    “Palliative care house calls, in particular, are often focused on patients undergoing difficult transitions or complex transitions of care,” explains Dr. Kwok. “This may include patients recently discharged from the hospital with more intense needs or those who are approaching hospice certification or enrollment that hasn’t yet been set up. So they will require extra support and additional care coordination. We also have patients at the other end of the spectrum who have outlived their original hospice designation and are now being unenrolled from hospice. This is very unfortunate because they have benefited from the services that hospice provided and it doesn’t mean that the patient’s goals have changed, but the uncertainty that the service could be taken away can lead to further difficulties.”

    Dr. Kwok shares examples that support the importance of including palliative care within the EGL House Call Program.

    • A patient with advanced dementia was on hospice care and likely to be unenrolled because he had been doing so well. Part of the reason for the patient’s wellbeing while in hospice was a high quality hospital bed and mattress that helped in healing and prevented pressure wounds. However, once the patient was no longer on hospice and transferred to a health care agency he probably would not qualify for that bed anymore. The family advised us that even if they were allowed to keep the bed, the mattress requires frequent servicing, which had been provided by the hospice service. Palliative care helped problem solve with the family and involved a social worker to coordinate a solution across different agencies.
    • A patient with Parkinson’s disease was well taken care of by several family members and caregivers, but was having a difficult time with disease progression and was at high risk for depression. “Advance care planning in the setting of depression presents a particular challenge as a patient can lose their joy in living,” says Dr. Kwok. When visiting this patient at home, the team noticed a whiskey collection and that sparked a conversation about how much that patient enjoyed a fine scotch until very recently. That became the topic of their conversations. “While his mobility was not going to improve, enjoying his favorite drink was something that we could potentially help with. This complicated situation was one in which the symptoms of depression and the ideas of what makes life meaningful came together and was made possible by the home care approach that would not have happened in a clinic or hospital.”

    The palliative medicine component of the EGL House Call Program is in its pilot phase, with the team establishing clinical and research protocols and compiling data on the needs of patients in the community and within the geriatric and palliative care outpatient practice of NewYork-Presbyterian/Weill Cornell.

    “We are assessing the needs of patients as they leave the hospital to determine if we are meeting their needs through the different services of our division and how we can improve continuity across settings,” says Dr. Kwok, who emphasizes that home care is the future of good medical care. “To truly be a patient-centered healthcare system, we need to get much better at providing care at home, especially for patients who are most frail and have the greatest difficulty getting to the hospital. The dynamic between the patient and clinician is so fundamentally different during home visits because you are a guest in the patient’s home. Additionally, our program is also educational, offering our learners a greater understanding of patient and caregiver experiences up close and personal. This is such a core part of the knowledge that we need in order to be good clinicians.”

      For more information

      Dr. Ian Kwok
      Dr. Ian Kwok
      [email protected]
      Dr. Karin Ouchida
      Dr. Karin Ouchida
      [email protected]
      Megan Lam
      Megan Lam
      [email protected]