UCSF’s Care at Home Program: Calming Chaos, Allowing Elders to Remain at Home

I met Eleanor on her 95th birthday in her small, cluttered bungalow tucked away in the Castro district of San Francisco. The home had a few layers of dust and needed a good deep clean. But below the dust and behind the clutter the home told a story. Scattered on shelves behind empty medication bottles, dirty dishes and random paperwork, were photos of earlier, healthier times.

Unfortunately, the months before I met Eleanor had been quite chaotic for her and her partner. She was in and out of various emergency departments due to falls, infections and overall decline because of her worsening dementia. Her arthritic bones made her unable to leave the home safely for medical care. Her lifelong partner, age 94, became her default caregiver, helping with everything from managing her medications to feeding and bathing her.

Caregiving is a difficult task for anyone but certainly for someone in their ninth decade of life who has health concerns of their own. Having no children and having outlived their friends and siblings, they were barely getting by and in desperate need of help.

This couple’s situation is certainly not unique. As our population grows older people will likely face many of the difficulties highlighted here, including lack of caregiving support, mobility issues, frequent falls and an inability to safely leave their home. They will also encounter high medication, food and rent costs, and an inability to pay other bills. Overall, they will have a harder time navigating the complexity of our healthcare system.

‘Team-based care is an important and appealing part of this work, especially in a field like geriatrics, because it focuses on using the strengths and expertise of each professional.’

As a society and as healthcare providers in the field of geriatrics, we are tasked with solving these issues. At UCSF our geriatrics practice is robust, and we have experts working hard to address not only the challenges listed above but many others. We have teams of clinicians and staff based in the office setting, hospital, short-term rehab centers and our Care at Home program. Our Care at Home program is uniquely equipped to help face these issues head on. Care at Home provides a team-based approach to primary care services as well as longitudinal palliative care to homebound older adults living in San Francisco County.

Our team consists of geriatricians, nurse practitioners, registered nurses, social workers and care coordinators. We know team-based care is an important and appealing part of work, especially in a field like geriatrics, because it focuses on using the strengths and expertise of each professional. In turn, this allows everyone to work to their full potential and ultimately provide better patient care. We know clinicians are happier when they get to work to their full potential and to feel as if their work is meaningful.

The field of geriatrics and in particular programs such as Care at Home recognize the “invisible” homebound older adult population, like Eleanor and her partner. These patients are isolated, and without services provided in the home, would have no access to care. Older adults have been historically underserved, even though they account for some of the costliest patients in our healthcare system. Being homebound is an independent risk factor for mortality. The Bay Area’s population is one of the oldest in the United States, with 20% older than age 60, and that number continues to grow.

The need for expert clinicians in geriatrics is in high demand. Waitlists for geriatric care, whether that be in a clinic setting, adult day program, or home-based primary care, are often very long. Sign-on bonuses and loan-payment programs are just some of the incentives used to try to recruit clinicians to address this overwhelming need.

The work we do is meaningful in not only reducing unnecessary emergency room visits and hospitalizations, but also in allowing older adults to maintain their autonomy, their sense of well-being, and their focus on quality of life in their later years. Gaining the trust of Eleanor and her partner via frequent home visits and engaging in meaningful conversations about what was important to them allowed me to focus on their goals and help their day-to-day lives. By tapping into resources with the help of social workers, we were able to get the home clean, get Eleanor signed up for in-home caregivers a few hours a week, and set up meal and medication delivery.

I adjusted her medications to focus on her comfort, reduce her pain, and help her get better sleep. I was able to enroll her partner into our program as well so he could receive much needed medical care. The chaos into which I had initially walked felt calm with the help and hard work of our geriatric team.

‘The chaos that I initially walked into felt calm with the help and hard work of our geriatric team.'

Students, fellows and other professionals from many fields rotate through our Care at Home program. Education is an important part of healthcare, but especially at an institution like UCSF and in the field of geriatrics. Our goal is to improve the care of older adults through innovation and thoughtful teaching. I have found students are often eager to start a career where they can give back to the community and find a sense of accomplishment in their work. What better place to do this than geriatrics, and by having experiences in rotations like Care at Home where they can see what possibilities there are after graduation.

Geriatrics, particularly in the home setting, challenges clinicians to think outside the box and demands creativity. To practice as a clinician in the home setting you must be an expert in your clinical skills and confident in your decision making. By providing care in an intimate setting such as a patient’s home, we become very connected and involved with our patients and their loved ones. The work can be quite rewarding. We are there for our patients and families often during the most difficult and challenging times in their lives. We follow our patients throughout the aging continuum.

Once enrolled in our program almost all patients stay with us until their death. Ultimately, after a few years as patients in our program, both Eleanor and her partner enrolled in hospice care, and never had to return to the emergency room or to be hospitalized. We worked hard to prioritize their comfort and keep them together safely at home. In the end, they both died within a week of each other in their home of more than 60 years and in accordance with their wishes.

Their story is a success and represents when things go right. Their story reminds me of why I love my work and why I’m hopeful that others will find this work meaningful and pursue the field of geriatrics.

Courtney K. Gordon, DNP, MSN, GNP-BC, ACHPN, is a geriatric and palliative care nurse practitioner in UCSF’s Care at Home program in San Francisco.

Photo credit: Shutterstock/imacoconut