Our team offers extended services to help older adults who could benefit from a consultation and those who have trouble traveling to their provider’s office due to functional or cognitive issues. Learn more about each of these services below.
CENTER FOR OLDER ADULTS
The Center for Older Adults provides a comprehensive outpatient consult service with an interdisciplinary team, which includes medical, nursing, rehab, nutrition, pharmacy and behavioral medicine for our older adult population who have begun to experience functional decline within the past year and/or are beginning to struggle at home.
Our Comprehensive Geriatric Consults comprise of 2-3 visits with an evaluation, recommendations, and short-term follow up when appropriate. Providers involved with the Center for Older Adults stay in close communication with the patient’s primary care provider with a goal of supporting the comprehensive care of their older adult patients. They will not implement recommendations from the consult without first gaining approval from the patient’s PCP.
Patient Criteria for Center of Older Adults:
- Older adults who are beginning to experience functional decline over the past 6-12 months – with cognitive and functional deficits emerging and/or those who are beginning to struggle at home.
- Older adult patients who need more frequent visits than is feasible for a primary practice to provide and can benefit from a comprehensive geriatric consult.
- Referrals made from Primary Care Provider offices directly to Center for Older Adults through eCW.
OLDER ADULTS HOUSE CALLS PROGRAM
The Older Adult House Calls Program provides nurse practitioner (NP) home visits to older adults 65 years old and over who are having a difficult time traveling into the provider’s office due to a functional or cognitive limitation. The NP works in collaboration with the patient’s primary care provider office, providing one-time acute type visits and in some cases a short-term follow up as needed.
Referrals for this program should be placed through eCW, using the outgoing referral function, and assigned directly to Erin Morgan, AGPCNP. Once received the patient will be contacted and a house call visit scheduled within 1-2 business days. Evaluation notes are completed and forwarded to the patient’s PCP.
FREQUENTLY ASKED QUESTIONS
Are there specific criteria that a patient must meet to be eligible for the house calls program?
The Older Adult House Calls program aims to serve older adults who are 65 years and over, who have a difficult time traveling into the provider’s office due to a functional or cognitive limitation. There should be an acute concern which requires evaluation by a nurse practitioner.
Currently, the Older Adult House Calls Program is available to patients living in Maine.
Does the patient have to be homebound?
No, patients do not need to be home bound to be seen by the Older Adult House Calls provider. The patient should however, have a functional or cognitive limitation that makes traveling into the office difficult.
How does the Older Adult House Calls Program collaborate with the patient’s primary care practice?
Older Adult House Call referrals are made through the patient’s primary provider office, YH walk-in or YH Emergency Department. The Older Adult House Calls provider will see the patient for a one time visit. In some instances, short term follow-up for acute medical issues. Evaluation and treatment notes are completed in eCW and will be forwarded to the patient’s primary care provider. If requested or deemed necessary based on clinical impression, the House Calls provider may reach out to the provider office via phone call during or after a home visit to coordinate the patient’s plan of care. Ongoing follow up should be provided by the patient’s primary care office and the patient should continue to see their primary care provider for regular visits.
How do I make a referral to the Older Adult House Calls program?
Referrals for a house call can be placed through eCW, using the outgoing referral function. The referral should include the reason the visit is being requested, pertinent background information regarding the patient, goals of care if known, and any known safety concerns in the home. Referrals should be assigned directly to Erin Morgan AGPCNP.
Can I call to make a referral or send a telephone encounter?
Phone calls and telephone encounters to provide additional information are always welcome and can be helpful to start the process of setting up a house call. However, a referral into eCW is also required as this is used for tracking purposes and helps to ensure all referrals are addressed.
What should I expect once I make a referral?
Once a referral is received, the patient will be contacted by the Older Adult House Calls provider within 1 business day, and a patient house call visit will typically be scheduled within 1-2 business days. Time and date of the visit will be documented within the referral for reference and tracking purposes. Once the patient is seen, a note will be documented in eCW and then forwarded to the primary care provider. Any additional follow up or care coordination required will be communicated with the primary care office.
Are there any circumstances that are not appropriate for a house call referral?
Acute psychiatric episodes do not fall under the scope of the House Calls Program. Also, the need for a house call visit should not be based solely on the availability of transportation or weather related challenges. Labs can be collected at visits as part of the patient’s care plan, so long as an assessment is also occurring and the visit is not exclusively for lab collection.
Can the house calls NP administer vaccines?
Vaccines could be given as part of a visit if the House Calls provider is already seeing the patient for another reason. The House Calls provider cannot make visits for the sole purpose of administering a vaccine.
Can I make a referral if the patient is followed by VNA?
Yes, the House Calls provider can see patients who are being followed by the VNA, as long as there is a specific need identified for advanced practice provider involvement in addition to the VNA.
Can I make a referral for a transitional care management visit (hospital discharge follow up)?
On a case by case basis, it may be appropriate for the House Calls provider to make a visit to see a patient for a follow up visit following a discharge from the hospital. The case manager at the primary practice or primary care provider can reach out to the House Calls nurse practitioner to discuss these types of visits.
What happens when a patient calls the “Older Adult House Calls Line” phone number (207-646-HOME)?
The Older Adult House Calls line phone number is answered by a care access representative in the YH Care Access Center. If the patient has an open referral to the house calls program, care access representatives will assist the patient in scheduling a home visit appointment. If there is no open referral, the patient will be directed to their primary care office to discuss their symptoms and determine if a house call is appropriate to meet their needs.