For some senior citizens, a doctor visit can take place in the living room.

Geisinger at Home was launched this past spring, and already 1,200 patients who have the Geisinger Gold Health Plan are taking part.

Janet Tomcavage, chief population officer with Geisinger, oversees the model and said there is a real need in our area for home health care for patients with complex health conditions.

“Sometimes it is a challenge for older patients to get out of the home,” Tomcavage said, “We recognized there was a real need for more access to primary providers and nurses.”

The first home visit began in April. By May, there were regular visits being made with several patients.

The team of professionals who typically visit with the patients is led by a primary care physician. Other visitors may include a registered nurse, dietitian, and possibly a social worker.

When necessary, the primary care physician or advanced practitioner may reach out to a specialist physician by phone. There may also be extended care needed from a pharmacist via telephone, too.

According to Tomcavage, the goal is not to have too many team members in the home, especially initially.

“We try not to overwhelm them,” she said.

Sometimes a social worker may be needed to assess the home and help provide needed support items such as new mattresses, lifting chairs, etc.

Other medical personnel may include leveraged mobile health paramedics who can provide necessary IV poles and services such as EKGs.

“The primary goal is ‘how do we improve services to help individuals stay in their home and make it more affordable?’” Tomcavage said.

The patients are chosen based on need from within the Geisinger Gold  Health Plan who also have Medicaid and Medicare. There is no co-pay or cost sharing for those who have this plan.

Tomcavage said it was started with only GHP patients in order to better learn the model and keep track with the Geisinger based system.

The patients live in counties within the core area of the Geisinger Health System, including Snyder, Union, Northumberland, Montour, Luzerne among others.

One of those patients is Florence Evert, of Bloomsburg. Evert is 84 years old and in a wheelchair with what she described as a host of medical needs. She has been a part of Geisinger Home since June.

“It has just been a wonderful program for me,” she said. 

Proactively engaging patients is a key part of the program, according to Tomcavage.

“We identify the patients in need. We go to see them at their home,” she said. “We don’t wait until there is an acute need. We do a home visit first to get a comprehensive assessment.”

This also includes identifying the patient’s social needs such as transportation, food, etc.

“About 20 percent have social gaps, such as food insecurity,” Tomcavage said, which can be due to a number of reasons.

Once of all of those needs are identified, a plan of care is put into place, such as how often the patient needs the visits.

Evert sees someone from Geisinger Home on an average of once a month unless there is a specific need.

“I love that I can call on the spur of the moment when I need them,” she said.

There is a toll-free line given to the patients enrolled with nurses on the other end. Tomcavage said the line receives as many as 120 calls a day.

Statistics in the system show how the load has been lightened in other departments. 

“We have seen a 60 percent reduction in emergency room visits among this population and 30 percent reduction in hospital admissions,” Tomcavage said.

Recently, Evert had cellulitis in her legs and a doctor was able to get her IVs with antibiotics in her home.

“Last time I had cellulitis, I was in the hospital for five days,” she said.

That does not mean a Geisinger Home patient may not ever need an ER visit.

“We are not replacing emergency care,” Tomcavage said, “if someone has chest pain, we send him to the ER.”

However, if the patient has a known cardiac condition and chest pain is not uncommon, a team member will likely treat the situation.

Fifty percent of the staff with Geisinger Home are employees within the system. The other half are new hires, Tomcavage said.

Communication within the model is a must, said Evert’s nurse case manager, Katie Fulkersin, RN, with Geisinger Home.

Fulkersin said Geisinger Home professionals not only stay connected to patients and fellow team members, but they also make efforts to link with home health services that are already in place. 

“We try to make sure we are all on the same page. We divide and conquer,” Fulkersin said.

Caregivers and family members also have access to the team for questions and concerns about their loved ones.

“Someone will always have eyes on them and watch out for them. It is a lot of communication,” Fulkersin said.

For more information, call the Geisinger at Home Care Team Call Center at 833-552-1852.