Rheumatologists on the road: A subspecialist's role in caring for the homebound

Abstract

Objective. By 2030, the number of permanently homebound individuals in the US will increase by 50% to reach 2 million. However, no medicine subspecialty consult services exist for this rising subset of the population. This pilot program establishes a rheumatology consult service for the Mount Sinai Visiting Doctors, the largest primary care academic home visit program in the nation serving more than 1,000 patients in New York City. Our service addresses the unmet need for homebound patients with rheumatic diseases, and secondarily provides an educational opportunity for trainees in community-based rheumatology. Methods. Using an electronic medical record, home-based primary care physicians sent consult requests to the Rheumatology Division. Initial assessments were made using the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire. Results. Over 12 months, 57 home visits were made: 31 new consults and 26 followup visits. Reasons for referral included medical management of a known connective tissue disease, question of inflammatory arthritis, and procedures. The demographics for new consults were as follows: 94% women, 45% Hispanic, and 80% between ages 60 and 101 years. Thirty-nine percent of patients had rheumatoid arthritis. Treatment interventions included addition of a diseasemodifying antirheumatic drug in 11 patients, 11 procedures, nonpharmacologic management in 8 patients, and a change in the dose of the existing medication in 5 patients. At the initial evaluation, the average RAPID3 scores for patients reflected high severity of disease. Conclusion. The number of consults and the severity of disease seen highlight the importance of a rheumatologist's role in the community, especially because the number of homebound patients will dramatically increase in the future.

“There Is Something Very Personal About Seeing Someone’s Face”: Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19

“…Participants also reported that video visits improved efficiency by allowing them to triage patients’ needs quickly and determine when in-person care was needed, for example, during an urgent care visit. Eliminating travel time allowed providers to schedule more visits, a critical benefit when many practices were short-staffed due to redeployments and illness, and improved access to specialists, a particular concern for the homebound population (Jain et al, 2011). The ability to expand capacity through video encounters could be a valuable asset for HBPC practices that are often financially challenged (Desai et al, 2008; Eric De Jonge et al, 2014).…”

Significant Unmet Oral Health Needs of Homebound Elderly Adults

“…Pilot models are needed to provide at least recognition of need for care for community‐dwelling homebound individuals effectively and efficiently, ideally in collaboration with the medical care being provided in the home given their debility. Prior work has shown the feasibility of specialty consultation services embedded in a home‐based primary care program . Given the current scarcity of in‐home dental care services and dental professionals providing home‐based dentistry, it may be more feasible to begin a referral‐based pilot of home‐based dental services within an established primary care program.…”

“…Prior work has shown the feasibility of specialty consultation services embedded in a home-based primary care program. 29 Given the current scarcity of in-home dental care services and dental professionals providing home-based dentistry, it may be more feasible to begin a referral-based pilot of home-based dental services within an established primary care program.…”

Home‐based primary care: A systematic review of the literature, 2010–2020

“…Twenty‐nine articles examined the scope of HBPC care delivery practice or evaluated HBPC care delivery models 4,13–34 …”

“…Five studies addressed the provision of mental health care within HBPC practices. [30][31][32][33][34] Reckrey et al captured the prevalence of mental illness among patients at an urban HBPC practice where 26% of patients were diagnosed with depression, 10% had anxiety disorders, and prevalence of pharmacologic treatment for these disorders was high (26% selective serotonin reuptake inhibitors, 21.5% antipsychotics). Researchers used these data to pilot an in-home psychiatry consultation service.…”