Models addressing urgent clinical needs for older adults with multiple advanced chronic conditions are lacking. This observational study describes a Community Paramedicine (CP) model for treatment of acute medical conditions within an Advanced Illness Management (AIM) program, and compares its effect on emergency department (ED) use and subsequent hospitalization with that of traditional emergency medical services (EMS). Community paramedics were trained to evaluate and, with telemedicine-enhanced physician guidance, treat acute illnesses in individuals' homes. They were also able to transport to the ED if needed. The CP model was implemented between January 1, 2014, and April 30, 2015 in a suburban-urban AIM program. Participants included 1,602 individuals enrolled in the AIM program with high rates of dementia, decubitus ulcers, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Participants had a median age of 83 and an average of five activity of daily living dependencies (range 0-6). During the study period, there were 664 CP responses and 1,091 traditional EMS transports to the ED among 773 individuals. Only 22% of CP responses required transport; 78% were evaluated and treated in the home. Individuals that community paramedics transported to the ED had higher rates of hospitalization (82.2%) than those using traditional EMS (68.9%) (P < .001). Post-CP surveys showed that all respondents felt the program was of high quality. Results support the potential benefits of CP and invite further evaluation of this innovative care model.

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.

Objectives To document the degree of symptom burden in an urban homebound population. Design Cross-sectional survey. Setting The Mount Sinai Visiting Doctors Program (MSVD). Participants All individuals newly enrolled in the MSVD. Measurements Edmonton Symptom Assessment Scale (ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other. Results ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia. Conclusion In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs.

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.

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This program helps fill a gap in medical education training. Program data suggest enhancement of students' teaching and leadership skills. A competitive application process demonstrates interest in such training. These results suggest that medical schools should offer and/or fund undergraduate teaching and leadership training.

Background: Home-based primary care for homebound seniors is complex, and practice constraints are unique. No quality-of-care standards exist. Objective:To identify process quality indicators that are essential to high-quality, home-based primary care.Design: 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.Participants: Two national panels whose members varied in practice type, location, and setting. Results:The panels considered 260 quality indicators and endorsed 200 quality indicators that cover 23 geriatric conditions. Twentyone (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. Limitations: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. Conclusions: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.Ann Intern Med. 2007;146:188-192. www.annals.org For author affiliations, see end of text. With the declining number of nursing home beds (1), patients' continued preference to remain in the home (2), and an increasingly aged population, the number of permanently homebound seniors will increase to more than 2 million in 20 years (3). These patients have difficulty accessing medical care and are increasingly receiving primary care through home-based primary care programs (4). As home-based primary care expands, however, tools to support, measure, and improve quality of care for these complex patients have not been developed. One such tool would be a comprehensive set of evidence-based process quality indicators that is developed by experts in home-based primary care.The Assessing Care of Vulnerable Elders (ACOVE) project has developed several quality indicator sets for ambulatory geriatric and nursing home patients (5, 6). These quality frameworks, however, cannot be simply adopted. Home-based primary care patients have higher mortality rates and shorter life expectancies than the ACOVE-studied populations, with goals of care that focus on quality, rather than prolongation, of life (7-9). Home-based primary care programs are often multidisciplinary efforts that emphasize coordination and continuity of care (10). Furthermore, processes of care vital to high-quality care of the homebound patient may have been overlooked by the ACOVE researchers. Given these findings, the Homebased Primary Care Quality Initiative (HPCQI), a multistep, national expert panel process, was completed. The study, by adapting and expanding on earlier ACOVE work, identified a set of e...

Although engraftment following in utero stem cell transplantation can readily be achieved, a major limitation is the low level of donor chimerism. We hypothesized that a lack of space for donor cells in the recipient marrow was one of the primary reasons for failure to achieve significant engraftment, and that donor T cells could make space in an allogeneic mismatched setting. We found that 3 × 105 C57BL/6 (B6) naive CD3+ cells coinjected with B6 T cell-depleted bone marrow (TCDBM) into 14- to 15-day-old BALB/c fetuses resulted in multilineage engraftment (median, 68.3%) associated with severe graft-vs-host disease (GvHD; 62 vs 0% with TCDBM alone). When 1.5 × 105 CD4+ or CD8+ cells were used, low levels of engraftment were seen vs recipients of 1.5 × 105 CD3+ cells (2.4 ± 1.1 and 6.6 ± 3.9 vs 20.4 ± 10.4%, respectively). To test the hypothesis that proliferation of T cells in response to alloantigen resulted in GvHD and increased engraftment, we pretreated naive T cells with photochemical therapy (PCT) using S-59 psoralen and UVA light to prevent proliferation. GvHD was reduced (60–0%), but was also associated with a significant reduction in engrafted donor cells (53.4 ± 4.2 to 1.7 ± 0.5%). However, when B6 T cells were sensitized to BALB/c splenocytes, treated with PCT, and coinjected with TCDBM, there was a partial restoration of engraftment (13.3 ± 2.4% H2Kb+ cells) with only one of nine animals developing mild to moderate GvHD. In this study we have shown that PCT-treated T cells that are cytotoxic but nonproliferative can provide an engraftment advantage to donor cells, presumably by destroying host hemopoietic cells without causing GvHD.