THE HOME ADVANTAGE

Words by Maryann Brinley / photographs by John Emerson

KANNAN SIVARAJU, MD, AND LAURA TOBIN, A GRADUATE OF UMDNJ’S SCHOOL OF NURSING

ATIENTS OFFER US FOOD. WANT US TO STAY FOR LUNCH. AND bring out the cookies. Lots of cookies,” laughs Laura Tobin, RN, MSN, ANP-BC, GNP-BC, describing her new job. The food, however, is not what it’s all about. Tobin is a 2010 graduate of the UMDNJ-School of Nursing’s (SN) Advanced Nurse Practitioner program and also holds a Master’s degree in Nursing from SN. She started working last summer alongside geriatrician Kannan Sivaraju, MD, at Town Medical Associates in Verona, NJ, when this family practice group launched a new transitional and home care program, designed for their growing number of geriatric patients in surrounding communities as well as for high-risk patients being discharged from Mountainside Hospital, Montclair, and Saint Barnabas Medical Center, Livingston. While not unique, this approach to medical care is certainly cutting-edge and offers distinct opportunities for job satisfaction. “We provide primary care for our patients who aren’t able to travel easily. We try to empower them to remain independent and maintain their lifestyles,” Tobin explains. “A 15-minute appointment in a typical office visit isn’t enough time to learn a person’s whole story. Patients are like puzzles. It takes time to figure out what is going on and to put their pieces together.”

For starters, this team allows more time for taking a medical history, including a thorough medication reconciliation. This turns out to be critical. “We don’t just look at a list of medicines. In the home, we check everywhere: the kitchen, the bathroom, the bedside, under the sink. It’s often not clear just what a patient is taking and poly-pharmacy is a huge problem for the elderly. These patients are frequently on so many medications that they can experience serious adverse effects,” Tobin says.

Sivaraju agrees, “With an elderly patient on medication, you have to consider kidney function. Older patients are different and should always be started on the lowest possible dose. Even their ability to handle antibiotics can be different from the general population. A lot of doctors, not trained in geriatrics, lack the knowledge to manage these cases. I’m particularly interested in continuity of care. The only part personally missing for us is the time spent in the hospital but we are working closely with the hospital discharge process and receive a summary of the patient’s hospital course. We get to know the patients completely and keep on learning, communicating and working with them, their families and caregivers. This is why I chose geriatrics.” It is all about holistic case management and requires a lot of coordination of care. Sivaraju points out, “By 2020, one-fifth of the population is going to be geriatric. The baby boomers are already there and many of them have multiple chronic health conditions.”

PHYSICIAN KANNAN SIVARAJU AND ADVANCED NURSE PRACTITIONER LAURA TOBIN CARE FOR PATIENTS GEORGE AND MADELINE LANZO IN THEIR HOME.

Both Tobin and Sivaraju shake their heads recalling the frail, elderly woman who met them at her door and appeared intoxicated. “Immediately, we focused on evaluating the medications for overdosing. This woman was in danger of falling. She was overmedicated and safety is the number one issue. Even when we know we are going into a hot spot like this one, we can deal with it. And every single case is different.” In this door-to-door service, the team can handle laboratory work, diagnostic imaging, ultrasounds, X-ray, and EKG — all right there in the home. Tobin and Sivaraju have also put together a seven-page “Resource Guide for Seniors and Caregivers” with essential agencies and contacts.

Thomas McCarrick, MD, is the managing partner in this large family practice that includes a total of seven doctors, four physician assistants and one nurse practitioner. McCarrick believes that the new program makes good sense. “There is a lot of financial pressure to keep people out of the hospital system. In our practice, we also wanted to take better care of our older patients, a demographic that is growing. These are people who can’t always get into the office for regular primary visits.” End-of-life care, especially, can be very expensive. So far, reimbursements by Medicare and private insurers don’t cover the full cost of providing this new service. “There are a number of studies that measure how it will impact the total cost per patient. But Medicare and the insurance companies just haven’t gotten on board with this yet.” Still, McCarrick is positive and explains, “It had become very unsatisfactory just talking to families about elderly patients with health issues and not being able to see these people regularly in the office. Sometimes, our only option was to send the patient to the ER. So we spent the last three years getting this program ready.”

In his research, McCarrick found:

• Twenty percent of Medicare patients discharged from acute care hospitals are readmitted within 30 days, with an estimated national cost of $17 billion.
• Fifty percent of the patients readmitted had no physician contact, and 70 percent of the surgical readmits were for chronic medical conditions.
• Recently studied models of transition care management have reduced rates of readmission by more than 30 percent.
• According to the Congressional Budget Office, 5 percent of Medicare beneficiaries account for more than 43 percent of the costs.
• Many chronically ill seniors lack nonemergency medical care. As a result, they repeatedly cycle through the ER, the hospital, and the post-acute nursing home care.

“We’ve been working with Mountainside Hospital and Saint Barnabas Medical Center to follow their high-risk patients after discharge,” Tobin explains. As reimbursement rules change, hospitals may be penalized by insurance companies and the federal government for patients who must be readmitted with the same diagnosis within 30 days. And some states are now limiting the number of hospital days per year for certain groups of patients, desperately looking for ways to cut costs. But it’s not just about the money for Tobin and Sivaraju. She says, “These people don’t want to go back to the hospital. It’s just not good, supportive care to be cycling back and forth to the hospital for more diagnostic tests when there may be no cure for a terminal or chronic illness. So our transitional program is about cost-saving as well as quality of life.” In those high risk situations, “We visit the patient’s home within 24 hours and continue to follow closely with visits and phone calls.”

Sivaraju says, “Geriatrics is on the top of the list for job satisfaction.” And Tobin, who has a Master’s in economics and once worked in a bank as well as an accounting firm, agrees. “This is very rewarding. I made the BIG change and started nursing school when my daughter Rebecca was 11 and son Michael was 9.” Her journey, which included years as a visiting nurse in Totowa, Verona and Millburn, as well as more than 10 years with St. Barnabas Hospice and Palliative Care in West Orange and Newark, has now taken her into a job where cookies are part of the total compensation package. “Our patients are so appreciative and very happy we are there.”