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Supporting Medically Complex Clients at Home

  • May 14, 2024
  • Cathy Gasiorowicz
  • 6-min Read

“I tell my clients all the time what a huge gift it is for me to have an entire hour to talk with them,” said Wendy Laine, MD, who joined Lifespark after 20 years as an emergency medicine physician. Nearly every day, these conversations uncover a long-standing concern, question, or need which the client never felt they had time to bring up with their other providers during their 15-minute clinic visit. “These concerns might not seem like a high priority from a medical perspective but they often have a significant impact on quality of life,” she said.

From Worry to Relief

To illustrate, Dr. Laine described a recent meeting with a client, a woman who is on several medications for chronic pain. Towards the end of their visit, her husband shared that his wife, the Lifespark member, was sweating profusely in the morning and that he was deeply worried she might have cancer. After talking with the client about the timing of her pain medications, Dr. Laine realized that there was a nine-hour period during the night when she wasn’t taking pain meds. “I explained that she might be experiencing early withdrawal symptoms and that we could find a solution for this,” she said. “It was an easy fix for a big worry they hadn’t had time to address before.”

During a different client visit, Dr. Laine learned from the Lifespark member, a woman with a complex history of surgeries, that for the past six months, she’d been having significant urinary frequency. “She actually mentioned this to one of her doctors, and he’d dismissed it as a something that just happens when you get older,” Dr. Laine said. In addition to her client not feeling heard by the providers, her symptoms weren’t taken seriously. “Based on her health history and what’s she’s told me, it sounds like there may be something else going on, so I’m helping her address that,” she said.

More Than Their Medical Profile

In addition to exploring unaddressed concerns, Dr. Laine asks her clients what really matters to them, something she believes is especially important for people living with complex health issues, such as heart disease, diabetes, kidney issues, or other serious conditions. “It’s one of the reasons I came to Lifespark—we ask that question,” she said. “Just the other day, I learned that one of my clients had spent her whole life volunteering for different organizations, but because of her medical issues, she wasn’t able to do what had always given her so much joy.”

With this deeper understanding of her client, Dr. Laine created specific goals to help “get her healthy enough so she can give back,” she said. “I don’t think most providers have the time to engage with people at this level, but it can make a huge difference, especially with medically complex clients.”  

Another advantage of Lifespark’s approach to complete senior health is seeing clients in their homes. “Whether we’re meeting in person or virtually, clients in the home setting seem more comfortable talking about their lives and their health which opens up dimensions you don’t get in a clinic visit,” she said.

Bringing the Clinic to the Client

For members, especially those with considerable mobility issues, Lifespark is able to bring many clinic services into the home. “One of our members with advanced kidney disease needs to see her nephrologist regularly, but we’re able to arrange in-home lab draws so she doesn’t need to make additional trips to her clinic,” Dr. Laine said.

 For members who’ve lost their primary care physician or for whom it’s a significant burden to see them, Dr. Laine can step into that role, permanently or temporarily, coordinating care with their subspecialists throughout the decision-making process. “If a member has a trusting, long-standing relationship with their doctor and wants to stay with them, we work hard to collaborate with their current health care team,” she said, adding that Lifespark’s providers don’t ever want to get in the way of a well-established relationship.

Minimizing the Need for ER Visits

Being available 24/7 is one of the biggest ways Lifespark helps clients avoid emergency room visits, Dr. Laine said. “We always tell our members to reach out to us the minute they start having symptoms,” she said. In one case, a member’s wife reached out to Lifespark after her husband had fallen. The couple didn’t want to go to the ER unless it was absolutely necessary, and because Dr. Laine was able to stop by to check him out and order in-home testing, they avoided a lengthy ER visit and countless medical tests.

“We’re able to see people quickly, which is tough to do at the clinic, or even at Urgent Care or the ER where wait times can be so long,” she said. “I saw this all the time when I was working emergency medicine: older adults who’d maybe fallen and had a skin tear but were now forced to wait in a crowded lobby for six hours or more.”

If a member does need to be hospitalized, Lifespark’s transitions team is there to support them after discharge, an especially high-risk time for people with complex conditions. “Generally, people leave the hospital with a visit summary, some prescriptions, and a reminder to see their doctor, but beyond that, no real guidance or support,” Dr. Laine said. The Transitions Team meets with the client in their home, usually within 24 hours, to make sure they have any new medications and whatever Home Health nursing or therapy services they might need to help them recover at home. “We’re able to support them in a way that reduces their risk of readmission,” she said.

Focused on Goals of Care

Dr. Laine has several clients who had been scheduled for tests or procedures by one of their subspecialists, but when she talked with them about their goals of care and whether they would want to move forward with treatment if the test revealed something, they said no. “Based on their response and their goals of care, I can suggest that doesn’t really make sense to undergo the procedure,” she said.  

One gentleman she met with was scheduled for an invasive procedure for sleep apnea, even though he wasn’t a good candidate for surgery. After talking with him about his sleep apnea and learning that he had very few symptoms, Dr. Laine reached out to a neurologist and they decided to try BiPAP before moving ahead with a potentially dangerous surgery that would require sedation.

“Those goals-of-care discussions give us a deep understanding of our clients’ values and what they want out of life, so we can talk about options always in the context of their goals,” she said. “It just makes a lot more sense than automatically ordering tests and procedures that aren’t designed for people with complex medical histories.”

To learn more about Lifespark’s mission and our approach to supporting elders at home, visit Lifespark.com.




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