Geriatrics Home Visit program team members are (l-r): Dorothy Ventriglio, associate director, Geriatric Services; Thao Nguyen, APRN; Mary Beth Zwicharowski, RN, geriatric care coordinator; Rosa Martinez, senior line representative, and Lourdes Rapuano, lead line representative, Geriatric Outreach Services; Iwona Lacka, MD; and Lynn Triebel, RN, geriatric care coordinator.
Lynn Triebel, RN, and her colleagues get a perspective on their patients’ lives many clinicians don’t.
“We are able to spend time with patients in their homes and, often with their families,” said Triebel, a geriatric care coordinator with Yale New Haven’s Geriatrics Home Visit Program. “We get an idea of what’s going on in their environment and how it might affect their health and well-being.”
Based on a successful program at Bridgeport Hospital, the New Haven-based Geriatrics Home Visit Program is a partnership between Yale New Haven Hospital and Northeast Medical Group. Led by geriatrician Iwona Lacka, MD, it also includes Mary Beth Zwicharowski, RN, geriatric care coordinator, and Thao Nguyen, APRN.
They provide comprehensive primary care to Greater New Haven residents 65 and older who are homebound due to physical and/or cognitive conditions. The typical program patient is in his or her mid-80s and has five or more chronic conditions, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease and dementia. The program has cared for more than 270 patients since it began in 2015.
“Easy access to primary care is critical for homebound elders,” Dr. Lacka said. “We ensure they receive the care they need, and help reduce unnecessary emergency department visits and hospital readmissions, which are particularly difficult for our patient population.”
The program started as a transitional home-visit program, caring for temporarily homebound elders for 30 days after hospital discharge, until they could get to their own primary care providers. Transitional services are still available, but most Geriatrics Home Visit Program patients stay with the program until the end of their lives.
“We changed our approach, because we found that patients and their families wanted ongoing primary care,” said Dorothy Ventriglio, associate director, YNHH Geriatric Services.
Program services include geriatric health assessments, physical exams, medical management, blood tests and referrals for nursing, physical and occupational therapy and podiatry services.
Referrals come from many places: the patients themselves or their physicians, visiting nurses or family members, and the inpatient units and ED on both campuses. Program providers tend to work closely with family members, many of whom are their older loved ones’ primary caregivers. Interactions frequently involve kind, but frank, discussions, Triebel said.
“We encourage family members to talk to their loved ones about what they need in order to have a good quality of life; and that may mean having a discussion about end-of-life care,” she said. “It’s challenging, but rewarding work. If our patients have a good quality of life through the end of their lives, we’ve done our jobs.”
For more information about the Geriatrics Home Visit Program or to make a referral, contact the Healthy Aging Line, 203-789-3275.
