RIGHT AT HOME
A CCHS nurse practitioner is providing care by going directly to her patients who need her most
ON ROUNDS | FALL 2016
BY BRETT JAILLET
PHOTOS BY ZACH RIGGINS
Lisa Brashier, CRNP, a nurse practitioner, was introduced to Wayne Hammett the way she has been introduced to many of her homebound patients—he arrived at University Medical Center by ambulance.
But it wasn’t for an emergency. It was for a routine visit.
Hammett was the victim of a gunshot accident 10 years ago, and now, unable to speak or walk, relies on the care of his parents and lives with them in their Northport, Alabama, home.
Any time he needed to go to the doctor’s office, whether he had fallen ill or just for a routine check-up, he had to call an ambulance.
“There was just no other way,” says his mother, Sheila Hammett.
Now, Brashier, who works at University Medical Center-Northport, visits Wayne Hammett for his routine examinations and calls on him if he is sick.
“She’s our angel,” says Sheila Hammett. “I tell everybody that. She is there when you need her.”
Wayne Hammett is one of the more than 20 homebound patients established at UMC or UMC-Northport, both operated by the College, for whom Brashier provides care. She takes two half days a month to travel to her patients and allows flexibility in her schedule should the need arise for an urgent appointment.
She also provides care two to three times a month for UMC patients living at Capstone Village, a retirement community located on The University of Alabama campus. Those visits she alternates with Dr. H. Joseph Fritz, a family medicine physician at UMC-Northport and assistant professor of Family Medicine for the College.
While some of her patients are older and not able to get around as easily, like those at Capstone Village, others are in their 20s. Some are diagnosed with mental health illnesses or developmental disorders. Some are physically disabled.
“Some of my patients have had strokes, some have early dementia, Huntington’s disease. Sometimes I follow hospice,” she says.
But they all have one thing in common: It is difficult for them to come to the doctor’s office.
“Maybe they have to take an ambulance, or a family member has to take time off of work to take them in—but it makes it difficult for them to have routine care,” she says.
Brashier noticed patients arriving by ambulance at UMC for their appointments before she began her home visits.
“I thought to myself, ‘That’s crazy. They are coming in to get their medicines refilled, and they couldn’t come in any other way,’” she says.
When UMC or UMC-Northport patients arrive by ambulance, they are seen by their provider while the ambulance crew waits. After the appointment, the crew transfers the patient home.
Linda Magno, who oversees a home-visit project for the Centers for Medicare and Medicaid Services, said in a recent interview that it’s sometimes so difficult for patients to get to the doctor’s office that “they tend to cope as best they can until things go downhill and they call 911.”
So, Brashier goes to the patients.
Brashier has long had an interest in caring for patients in their home. She worked as a home health nurse before she became a nurse practitioner, and then she joined a practice for 15 years where she saw the same patients all the time and got to know them well.
She joined the College in 2013, and has seen patients in UMC’s Family Medicine Clinic and Faculty-Staff Clinic. She transitioned to UMC-Northport after it opened in July 2015.
It wasn’t long after she first joined the College that she began her home visits. When she got word that a UMC physician who had a panel of homebound patients was leaving, she jumped at the chance to continue their care.
“I saw a need,” she says. “I was looking for a way to develop a practice that would let me see the same people continuously. That’s what makes me happy.”
“BECAUSE THESE PATIENTS’ SCHEDULES ARE SO DIFFICULT, HOME VISITS HELP WITH THEIR CONTINUITY OF CARE. OTHERWISE THEY MIGHT BE SEEING A DIFFERENT PROVIDER EVERY TIME.”
—Lisa Brashier, CRNP, Nurse Practitioner at University Medical Center-Northport
Home visits can provide additional benefits for the patient, Brashier says. First, eliminating the ambulance ride to the doctor makes a big difference for the patient’s costs.
“I save the family a significant amount of money as visits to a doctor’s office (via ambulance) are not covered by insurance,” she says.
And visiting a patient in his or her home can improve the care provided.
“Because [these patients’] schedules are so difficult, home visits help with their continuity of care,” she says. “Otherwise they might be seeing a different provider every time.”
Plus, when a patient is seen only in the physician’s office, health issues can be dealt with in isolation, says Dr. Soeren Mattke, a senior scientist at RAND Corporation, a nonprofit research organization
“When they go to the physician, they have maybe 10 minutes’ face time,” Mattke says. “So what often happens is the conversation focuses on what is the most pressing issue that day. But many other things that also have to be handled really never get any attention.”
By 2030, 70 million US citizens will be older than 65, and a substantial number of people will live at home with disabilities that prevent them from traveling to medical facilities, according to the American Academy of Family Physicians.
The US Department of Veterans Affairs’ Home Based Primary Care program uses a multidisciplinary care team to care for older patients in need home of visits, according to the AAFP. The program demonstrated fewer hospital admissions, shorter lengths of stay, reduction in readmission rates and reduction in long-term care facility stays.
The College’s Family Medicine Residency has built home health visits into its curriculum. It is a national requirement that family medicine residencies teach physicians to care for patients in multiple settings, including the home. Dr. Catherine Scarbrough, associate director of the Residency, says that residents in their second year of training identify patients who might be candidates for home visits.
“They might be elderly and have multiple medical issues, and so it’s hard for them to get into the doctor’s office. Or they might have transportation issues.”
Sometimes patients may just not show up for appointments, Scarbrough says. That could be for multiple reasons.
“Maybe they’re in a rural area. Maybe they’re depending on a neighbor who has a car to get to the doctor. But maybe that neighbor has health issues, too,” she says.
“WE‘RE IN THE RUSH OF HEALTH CARE TODAY, AND WE’RE ALL BEING PUSHED INTO A BOX AND HAVING TO SEE SO MANY PATIENTS PER HOUR. A HOME VISIT GIVES US THE TIME TO GET TO KNOW THESE PATIENTS AS A PERSON, TO SIT DOWN WITH THEM, TO LEARN ABOUT THEIR BACKGROUND, THEIR FAMILY SITUATION AND GET BACK TO WHAT DOCTORING AND MEDICINE WERE MEANT TO BE.”
—Dr. Catherine Scarbrough, associate director of the College’s Family Medicine Residency
The residents then have the option of seeing the patients independently, working together in pairs or as a group, or they can coordinate with Brashier. Sometimes she accompanies the resident visiting his or her patient, or the resident might join Brashier on her house calls.
Home visits may soon be incorporated into an elective offered by the Residency, Scarbrough says. And eventually, the College wants to partner interprofessionally with other entities on campus, such as the UA Capstone College of Nursing or the School of Social Work.
Practicing in a patient’s home exposes residents to a different model of providing health care, and they learn more about the patient, Scarbrough says
“I think it’s really important. We’re in the rush of health care today, and we’re all being pushed into a box and having to see so many patients per hour,” she says. “A home visit gives us the time to get to know these patients as a person, to sit down with them, to learn about their background, their family situation and get back to what doctoring and medicine were meant to be.”
Brashier says she does learn more about her patients when she is in the home. She is able to look closely at their home environment and see how that can factor into their health.
“It gives perspective to why something in the clinic that sounds so simple is actually difficult when the patient gets home,” she says.
For instance, she had a patient with acute pancreatitis who found herself in the emergency room twice a week or admitted to the hospital every other week. She was referred to Brashier for a home visit to see if there was something missing.
Brashier found that none of the patient’s prescription bottles were labeled for what they treated, so the patient was not taking them.
“I made weekly visits for about a month, and she’s been in the hospital only twice in the past six months,” Brashier says.
Her visits with Hammett are not weekly, but when he is ill with a fever, she can visit him right away instead of his mother having to call an ambulance. Routinely, Brashier gives him an exam, checks the glucose levels for his diabetes, asks him questions, to which he responds as he is able, and she visits with his mother.
“I really like making home visits because it lets me connect with the patient and the family on a different level than when I’m in the office,” she says. “I can spend more time with the patient during a home visit. These families are so very grateful that I can make home visits. At the end of the day, I feel like I have done something useful for those I’ve seen.”
The University of Alabama
College of Community Health Sciences
850 Peter Bryce Boulevard
Tuscaloosa, AL 35401
Tuscaloosa, AL 35487