Meeting the Complex Needs of Older Adults in Primary Care

Hands holding flower


Mr. G was hospitalized for five days due to an ischemic stroke related to chronic, uncontrolled hypertension. He was subsequently transferred to a post-acute rehabilitation facility due to left sided weakness, mild aphasia, and general malaise. As discharge plans were being formulated, it became apparent that Mr. G would have difficulty accessing primary care in an office setting for several months as travel would take considerable effort and be taxing on him and his wife. Luckily, his established primary care providers offered home-based services. As his nurse practitioner, I communicated with a facility-based provider to coordinate his transition home, ordered certified home health care, and visited him within two days of discharge to ensure continuity of care and early detection of conditions that would warrant immediate intervention. My orders for home care included skilled nursing, physical therapy, occupational therapy, and speech language pathology to facilitate progress towards the best attainable health outcomes. Mr. G arrived home via ambulette to a fully equipped environment that included a hospital bed and raised toilet seat based on his current functional level. During my initial visit, a comprehensive evaluation uncovered continued elevated blood pressure despite his prescribed medication regimen which had been effective while he was in the facility. I collaborated with the home care RN to initiate remote physiologic monitoring at home and used the trended vital sign reports to safely and effectively titrate the medication dose to control his blood pressure. Mr. G made significant progress over the next two months and was discharged from home care with near normal ambulation, dexterity, speech, cognition, and activity endurance. He continued outpatient therapy for several months and followed up in the primary care office regularly.

Mr. G was very motivated to adopt and maintain healthy habits yet he was fearful that another stroke could occur in the future. He and his wife had never discussed his wishes in the event he could not make decisions for himself. Over a period of time, we discussed issues related to advance care planning. He worked with an elder care attorney to establish a power of attorney and health care proxy and was able to articulate his preferences for care in a variety of clinical circumstances. With these safeguards in place, Mr. G and his wife felt comfortable that there would be guidance available in the event of an unexpected health event. At each follow up visit, it was obvious that Mr. G regained a sense of normalcy. During his annual wellness visit, he disclosed that he had recently experienced a fall but didn’t think it was a serious event as he had no injuries. He was again referred for outpatient physical therapy to improve his balance and muscular strength in an effort to prevent future falls. To date, Mr. G is living a vibrant and full life feeling confident in his health and continually working to remain well.

This case illustrates the importance of primary care, especially in the older adult population. With continued emphasis on insurance reimbursement for services that minimize unnecessary hospitalization and Emergency Department use, an improved quality of life is attainable. Primary care practices are incentivized to provide care that is interprofessional, coordinated and preventive in nature. In this case, additional practice revenue was obtained by billing for transitional care management, home care plan oversight, advance care planning, and the annual wellness visit. More importantly, the health outcomes achieved enabled Mr. G to live a robust and satisfying life.


Read the entire September 2023 newsletter here