<P>Spring 2014 | UCSF MAGAZINE29 Aging, she included social workers and psychologists, too. Each par- ticipating patient is assigned a team, which is guided by the patients primary care provider. To start with, a nurse practitioner and a social worker assess the patient in his or her home, then the team members meet weekly to share their expertise in developing and monitoring a highly individualized care plan. Kao also oversees UCSFs Housecalls program, which embodies why individualized, team-based care is effective – and is gaining steam. The number of house calls made in the United States on homebound patients covered by Medicare has grown steadily over the past decade, from 1.6 million in 2001 to 2.6 million in 2011, according to the American Academy of Home Care Physicians. Staffed by geriatricians and a gerontological nurse practitioner, Housecalls serves more than 160 homebound, mostly low-income San Francisco seniors. For many, the Housecalls visits are their only lifeline to the health care system besides the emergency room. The program also connects patients with community services. Getting people hooked up to social services is a critical part of caring for them at home, explains Associate Professor Rebecca Conant, MD 96, a resident alumna, and a national expert in the field. Home visits convey the big picture, she says. We see whats going on in terms of family support, living conditions.... Do they have adequate food? Heat? You dont get that in a clinic. The team also meets spouses, children, and caregivers; hears life stories; and learns what the patients want out of their health care as they face the twilight of their years. Knowing their goals can avoid hospital visits that might be both costly and unhelpful. Recently, one of Conants patients suffered a stroke. After a long conversation with the patients wife, who was adamant about keep- ing him at home, Conant decided the best intervention was a home health referral to help with his care and with modifying his diet. The hospital could have run a battery of tests to assess the damage, but in the end that wouldnt have made a difference in his recovery, she says. So there was no ambulance trip, no emergency room visit, no hospitalization. Kaos patient Hellen Aitel became a Housecalls participant in early 2013. It was like the clouds parted and the sun came shining through, recalls her son, chuckling quietly. It made everything so much easier on her – and me. One of the early questions Dr. Kao asked, he continues, was ‘Whats important? The list for Aitel wasnt long: to walk again, to get relief from her arthritis pain, and to remain where shed lived for 50 years. My mothers life revolved around her home, Stephen Aitel says. Hellen Aitels team included home health nurse Barbara Schubach and physical therapist Jelin Hoh. They and Kao helped the 92-year- old walk again and encouraged her to be honest about her pain. She was afraid of being perceived as a whining little old lady, says her son. They were able to get through to my mom and took amazing care of her. Hellen Aitel also wanted to stay at home as long as possible. And darned if they didnt do it, he says, choking up. She died in late 2013, peacefully, at home. Helen Kao, director of geriatric clinical programs, while making a house call on Hellen Aitel in 2013. The fastest-growing demographic in the United States is people 85 or over.</p> <UL><LI><a href="http://www.mzines.net/publication/618/aelvmorax/1/1/">Front-Cover</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/2/2/">Inside-Front-Cover</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/3/3/">Page-1</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/4/4/">Page-2</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/5/5/">Page-3</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/6/6/">Page-4</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/7/7/">Page-5</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/8/8/">Page-6</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/9/9/">Page-7</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/10/10/">Page-8</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/11/11/">Page-9</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/12/12/">Page-10</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/13/13/">Page-11</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/14/14/">Page-12</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/15/15/">Page-13</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/16/16/">Page-14</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/17/17/">Page-15</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/18/18/">Page-16</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/19/19/">Page-17</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/20/20/">Page-18</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/21/21/">Page-19</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/22/22/">Page-20</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/23/23/">Page-21</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/24/24/">Page-22</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/25/25/">Page-23</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/26/26/">Page-24</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/27/27/">Page-25</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/28/28/">Page-26</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/29/29/">Page-27</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/30/30/">Page-28</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/31/31/">Page-29</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/32/32/">Page-30</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/33/33/">Page-31</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/34/34/">Page-32</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/35/35/">Page-33</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/36/36/">Page-34</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/37/37/">Page-35</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/38/38/">Page-36</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/39/39/">Page-37</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/40/40/">Page-38</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/41/41/">Page-39</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/42/42/">Page-40</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/43/43/">Page-41</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/44/44/">Page-42</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/45/45/">Page-43</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/46/46/">Page-44</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/47/47/">Page-45</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/48/48/">Page-46</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/49/49/">Page-47</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/50/50/">Page-48</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/51/51/">Page-49</a></LI> <LI><a href="http://www.mzines.net/publication/618/aelvmorax/52/52/">Back-Cover</a></LI> <LI><a href="http://www.mzines.net/publications/618/x/sitemap.xml" target="_blank">site map</a></LI> </UL>

 

If you would like to view publication without flash plugin, please click on link below




To view your publication, you need to upgrade your Flash Player

Click here to install latest flash player.