Clinical Rotation: Home Based Primary Care

Next up in rotations was Home Based Primary Care (HBPC).

This was an awesome rotation and I absolutely loved it!

I’m not sure about other internships, but I’m fairly certain HBPC is fairly unique to VA.  HBPC is pretty much what it sounds like – getting medical care in the home.  HBPC teams are composed of an MD, a nurse or PA, a social worker, a PT/OT, and an RD.  When a Veteran is homebound, the Veteran is considered for HBPC and the MD or a nurse visits the Veteran at their home.  If the Veteran meets certain qualifications, then he or she is admitted to the HBPC program.  Each member of the HBPC team then goes to see the Veteran in his or her home, does an assessment and decides how often they need to follow up with the Veteran.

Doing a nutritional assessment in the home is different than doing one in the hospital.  In the hospital, if the patient is telling you they eat healthfully, you can’t tell if they’re just saying what you want to hear or if they are being truthful.  (Although, labs can sometimes give you an idea.)  In the home, if a patient tells you that they eat well, you can always pointedly look at half-eaten bags of cookies and chips and ask, “How often are you eating these?”  With home nutritional assessments, I felt like I got a better sense of how the patients were doing nutritionally.  You could tell if their kitchen equipment was being used.  You could get a better idea of if they could only microwave food or they could cook.  You could look around and look for signs of pests.  If you saw something that worried you that wasn’t nutrition related (for example, uneven carpet that could be tripped over), you could immediately let the OT or SW know.  In HBPC, you might only see 1-4 patients in a day while you might see double or triple that in the hospital.  This is partly due to the travel you have to do between homes and partly because the HBPC visits take longer due to the complex issues of the patients.

HBPC requires skills that you develop in all of your rotations – counseling, geriatrics, nutrition focused physical exams, tube feeding – plus some extra skills like being familiar with all sorts of medical equipment.  I got to see what kind of medical equipment one can purchase for the home – things to make it easier for the patient and for the caregiver.  We brought some of our own equipment, too.  We ended up using this portable wireless wheelchair scale which reminded me of something out of science fiction.

As part of my rotation, I also assisted with a nursing home inspection.  I think I was the only intern to participate in a nursing home inspection during HBPC – everyone else did that during Geriatrics.  It really just depends on the inspection schedule and what rotation you’re in.  The nursing home inspection was interesting.  Since the VA doesn’t have the resources to build nursing homes everywhere to care for the Veterans who need skilled care, the VA contracts out with established facilities.  However, the facilities have to meet VA standards so a team comprised of people from engineering, nursing, social work, long term care, and nutrition go out and inspect the facility on a regular basis.  My preceptor and I inspected the kitchen, the serving areas, training records for the kitchen staff, temp logs, food storage areas, expiration dates…everything associated with a regular food service safety and quality inspection.  Plus, we also inspected the contract the facility has with their RD and her records associated with the Veterans at the facility.  I’m not sure what the social work or nursing teams look for (I can make some guesses, though), but we rode with the guy from engineering and he was looking at building safety – fire alarms, electrical outlets, sprinkler systems, etc.  It was a cool experience.

I know if I don’t end up doing HBPC with the VA, there are companies that provide home health nutrition.  However, I really loved the fact that I worked with a team and I loved the team I worked with.  While you work with a team in all rotations, this felt different- more relaxed, more congenial.  We shared an open office (meaning, everyone was in one big room with workstations) which made it so easy to immediately let another healthcare provider know something we might have seen that we thought they needed to know about right away.

While I loved HBPC, it’s not for everyone.  Some people are uncomfortable going into other people’s homes.  You might feel that some of the neighborhoods or homes are unsafe to enter.  I never felt that way, but I know some of the other interns mentioned those things.  Some interns had horror stories of disgusting homes crawling with bugs, but I never did, and I suspect that everyone’s definition of “disgusting” is different, as is everyone’s tolerance of bugs.  (I’m not going to be bothered by twenty spiders, but someone else might freak out at one.) As an intern, you never go alone, and part of the initial assessment done before the patient is even accepted into HBPC is to gauge how safe the situation is for the healthcare providers.  HBPC kind of reminded me of Meals on Wheels because depending on my route for MoW, I sometimes went into people’s homes to deliver their meals.

If you like the idea of providing personalized healthcare to homebound individuals and helping to keep them out of the hospital, you might like HBPC.  Or, as in my case, you might really love it.




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