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Elder Medical Care

August 20, 2019
For some older patients living with serious chronic health problems or life-threatening illnesses like advanced cancer a trip to the doctor may not be feasible. But that care is still an essential part of keeping that person as healthy and comfortable as possible. To ensure older patients in this situation have access to the care they need, GBMC and Gilchrist bring the care to the patient at home. Mary Beth Marsden talked with Beverly Ruiz, MS, CRNP, team lead for the Elder Medical Care Home Program at GBMC, and Leanna Hoover, MSN, NHA, director of Elder Medical Care for Gilchrist to learn more about how these programs work.

“Patients with chronic conditions or serious illnesses can face frequent health crises,” explained Beverly. “These crises can lead to acycle of hospital, rehab, home that repeats over and over. Our goal is to break that cycle and intervene before the patient ends up back in the hospital. To do that, our team, which includes primary care physicians, nurse practitioners, and social workers, brings primary care services to people who are home restricted.”

In addition to making sure people who can’t leave home are getting the care they need, this approach has other benefits. “The home setting is more conducive to healing,” said Leanna. “We become part of a broader care team that includes the patient’s family. And the family becomes more engaged and takes more ownership of disease management. Outcomes are better when patients are in their own environments.”

The services that the GBMC and Gilchrist programs provide are different than skilled nursing home healthcare services. Beverly and her team provide a wide range of primary care services, including reviewing medications, addressing symptoms and concerns that the patient or family has, and connecting them to additional services like medical equipment and home healthcare support. They also talk with the patient and family to learn what their goals of care are, whether that’s remaining at home and managing symptoms or aggressive treatment.

“Everyone needs a caregiver, whether they can get out to the doctor’s office or not,” added Beverly. “Rather than ending up in the ER frequently, we bring the care and support to our patients.”

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