Rheumatologists on the Road: A Subspecialist’sRole in Caring for the HomeboundRUCHI JAIN, SUMA DASARI, THERESA SORIANO, LINDA DECHERRIE, AND LESLIE DUBIN KERR

Objective. By 2030, the number of permanently homebound individuals in the US will increase by 50% to reach 2million. However, no medicine subspecialty consult services exist for this rising subset of the population. This pilotprogram establishes a rheumatology consult service for the Mount Sinai Visiting Doctors, the largest primary careacademic home visit program in the nation serving more than 1,000 patients in New York City. Our service addresses theunmet need for homebound patients with rheumatic diseases, and secondarily provides an educational opportunity fortrainees in community-based rheumatology.Methods. Using an electronic medical record, home-based primary care physicians sent consult requests to the Rheu-matology Division. Initial assessments were made using the Routine Assessment of Patient Index Data 3 (RAPID3)questionnaire.Results. Over 12 months, 57 home visits were made: 31 new consults and 26 followup visits. Reasons for referral includedmedical management of a known connective tissue disease, question of inflammatory arthritis, and procedures. Thedemographics for new consults were as follows: 94% women, 45% Hispanic, and 80% between ages 60 and 101 years.Thirty-nine percent of patients had rheumatoid arthritis. Treatment interventions included addition of a disease-modifying antirheumatic drug in 11 patients, 11 procedures, nonpharmacologic management in 8 patients, and a changein the dose of the existing medication in 5 patients. At the initial evaluation, the average RAPID3 scores for patientsreflected high severity of disease.Conclusion. The number of consults and the severity of disease seen highlight the importance of a rheumatologist’s rolein the community, especially because the number of homebound patients will dramatically increase in the future.

IntroductionIn the next 20 years, the number of permanently home-bound individuals in the US will increase by 50% to reach2 million. In 2030, 20% of the population will be olderthan 65 years of age (1). These statistics demonstrate thegrowing need for medical care for this subset of the USpopulation, for both primary care medicine and medicinesubspecialists. Home-based primary care (HBPC) modelsexist throughout the nation, but have been relatively slowto develop. We know from experience that the inadequacyof these programs has been associated with increasedemergency room visits, hospitalizations, caregiver burn

out, and most importantly, patient suffering (2–6). To ourknowledge, there are no established medicine subspecial-ist consult services reported in the literature for this risingsubset of the population until this recent initiative wasstarted.

The basis for this pilot study stemmed from a successfulmodel of HBPC: in 1995, 3 Mount Sinai Medical Centermedicine residents established the Mount Sinai VisitingDoctors program to provide primary care to the home-bound in East Harlem, New York. Today, it has grown tobe the largest academic home visit program in the US,serving more than 1,000 patients throughout New YorkCity (1,2). Despite its success in the realm of primary care,however, the Mount Sinai Visiting Doctors have only hadintermittent psychiatric consult services, and no other in-put from any medicine subspecialists. The Visiting Doc-tors registry documents that 91% of these patients needhelp with 1 or more activities of daily living (ADLs), and98% with independent ADLs (1). Much of this disabilityarises from musculoskeletal problems that rheumatolo-gists can treat.

Therefore, our purpose in establishing a rheumatologyhome visit program was to address a currently unmet needfor homebound individuals in the community by provid-

Ruchi Jain, MD, Suma Dasari, MD, Theresa Soriano, MD,Linda DeCherrie, MD, Leslie Dubin Kerr, MD: Mount SinaiMedical Center, New York, New York.

Dr. Soriano has received an honorarium (less than$10,000) from Finger Lakes Region Geriatric Education Cen-ter.

Address correspondence to Ruchi Jain, MD, Mount SinaiMedical Center, Department of Medicine, Division of Rheu-matology, 1 Gustave L. Levy Place, Box 1244, New York, NY10029. E-mail: ruch1119@yahoo.com.

Submitted for publication April 10, 2011; accepted inrevised form June 21, 2011.

Arthritis Care & ResearchVol. 63, No. 10, October 2011, pp 1482–1485DOI 10.1002/acr.20539© 2011, American College of Rheumatology

BRIEF REPORT

1482

ing consultations in the treatment, management, or diag-noses of rheumatic diseases. By meeting these needs, wehoped to improve the quality of life, to decrease pain andsuffering, and to improve mobility of this populationthrough targeted treatments. Secondarily, this initiativealso provides education for fellows, residents, and medicalstudents in a unique learning environment from patientsin the community. These trainees were given an insightinto community-based rheumatology by encountering pa-tients with late-stage debilitating disease.

Materials and MethodsHBPC physicians sent consult requests to the Rheumatol-ogy Division via an electronic medical record. Rheumatol-ogy fellows, accompanied by either internal medicine res-idents or medical students, saw 6 patients per month onaverage in their homes. Since this was a pilot study incor-porating community home visits into a fellowship curric-ulum apart from regular outpatient clinics and inpatientresponsibilities, 2 or 3 patients were seen in a half daytwice a month. Patients were seen throughout Manhattan.Demographics, reason for consult, disease activity on ini-tial evaluation, and treatment intervention were recordedfor each patient. Attendings precepted via telemedicineand photos, and saw patients in the home for complicatedcases. For each new consult, patients seen were evaluatedfor appropriate followup. The Routine Assessment for Pa-tient Index Data 3 (RAPID3) score was used as an objectivemeasure of clinical disease activity (7). The RAPID3 scoreincorporates 3 subsets of the Multidimensional Health As-sessment Questionnaire: physical function, patient globalassessment for pain, and patient global assessment foroverall health in a tallied score. A score greater than 13

reflects high severity, 7–12 reflects moderate severity, and4–6 reflects low severity of disease.

Results

Over 12 months, 57 home visits were made: 31 as newconsults and 26 followup visits. The most common rea-sons for referral included: 1) medical management ofknown arthritis/connective tissue disease, 2) question ofinflammatory arthritis, 3) question of disease activity, and4) procedures: intraarticular injections, arthrocentesis, andbursa drainage. The demographics of new patients seenwere as follows: 94% were women, 45% were Hispanic,and 80% were between ages 60 and 101 years. Twenty-sixpatients lived alone or with a home health aide and 5patients lived with other family members.

The following diseases were seen, either as having thediagnosis prior to our evaluation or given a diagnosis afterour assessment: 39% percent of patients had rheumatoidarthritis (RA; all had established diagnoses), 30% of pa-tients seen also had osteoarthritis (as a single disease orconcomitant with another rheumatic diagnosis; �30% ofthese cases were given this diagnosis after our encounter),and 19% had crystalline arthropathies (�50% of thesecases were given this diagnosis after our encounter). Onepatient each having an established diagnosis of psoriaticarthritis, progressive systemic sclerosis, and polymyositiswere also seen.

Treatment interventions included the following: addi-tion of a disease-modifying antirheumatic drug (DMARD)in 11 patients, 11 procedures, counseling in 8 patients, anda change in the dose of the existing medication in 5 pa-tients. At the initial evaluation, the average RAPID3 scorefor patients with RA was 22.4 and for patients with crys-talline arthropathy was 19.3, reflecting high severity ofdisease. One patient with psoriatic arthritis on initial eval-uation had a RAPID3 score of 21 (high severity); afterintervention, the score was 11 (moderate severity). Onepatient with diffuse scleroderma had a RAPID3 score of20.3 (high severity).

The following is representative of the cases encounteredin consultation.

Case 1. We were asked to see a 77-year-old woman witha medical history significant for atrial fibrillation, hyper-tension, and diabetes mellitus that were well managed byher HBPC physician, who had been seeing her for manyyears. Although she had seropositive erosive RA, she wasnot being treated with DMARDs because she was home-bound. On initial examination, she had more than 12swollen and tender joints as well as contractures. Her painwas being palliated by opiates, and she was afraid of takingprednisone, given her history of diabetes mellitus. Werecommended methotrexate and a short course of predni-sone. Initially, the patient refused to take these medica-tions. However, with continued followup, not only did wegain her trust but she also became more debilitated andnow bedbound. She finally agreed to take methotrexate/steroids and her synovitis and mobility have improved.

Significance & Innovations● In the next 20 years, the number of permanently

homebound individuals in the US will increase by50% to reach 2 million. However, the culture ofmedicine subspecialists providing care for pa-tients in their homes has not followed the fewprimary care home-based models that exist in thenation.

● Many individuals are homebound secondary tomusculoskeletal incapacities and diseases thatrheumatologists treat, and primary care physiciansmay not be equipped for caring for this aspect oftheir disability.

● This new initiative reveals the extent and highseverity of diseases seen in this hidden subset ofthe population, and demonstrates a rheumatolo-gist’s important role in caring for these patients.

● To our knowledge, this is the first reported studyof medicine subspecialists providing care for thehomebound population, and the first reported ed-ucational endeavor in community rheumatologyin a fellowship program.

Care of Homebound Individuals with Rheumatic Diseases 1483

Case 2. A 37-year-old woman with a history of rapidlyprogressing diffuse scleroderma that began at age 35 yearswas seen in her home. She was not only homebound, butalso bedbound secondary to severe skin thickening andcontractures. The patient had severe skin manifestationswithout internal organ derangements. We started her onD-penicillamine. Per her primary care provider and care-taker, the patient had been experiencing anterior shoulderpain and upper back pain for some time that was thoughtto be musculoskeletal in origin. However, when we sawher, our concern was of a possible pulmonary versus car-diac cause of her pain. She was admitted to the hospitaland we were not surprised to learn that she had largepulmonary embolisms. She is currently being anticoagu-lated.

Case 3. A 38-year-old woman with morbid obesity,schizophrenia, and psoriatic arthritis was initially seen inconsultation by a rheumatologist as an outpatient and wasstarted on methotrexate for her active psoriatic arthritis.She was then lost to followup because she stopped comingto her appointments. The patient was homebound primar-ily by her psychiatric illness and obesity. When she wasseen in her home, the patient was experiencing dactylitis,as well as pain and swelling of her knees, wrists, andankles. We reinitiated methotrexate therapy as well as abrief course of steroids, and her synovitis has improved.

Discussion

The number of permanently homebound patients will in-crease in the next 20 years. As these statistics show, therewill be a greater need for providing care to patients in theirhomes. Not only will primary care providers (PCPs) beespecially important in this role, but also subspecialists inproviding a multidisciplinary approach for comprehen-sive care. Although there are PCPs that make house calls,there has not been an established culture of medicinesubspecialists that commonly incorporate home visits intotheir practices in the US. With the statistics outlinedabove, and the growing emphasis on the patient-caremodel in the home, there will be a paradigm shift in theway subspecialists may practice medicine in the future (3).

There are few examples, however, of other specialiststhat provide care to the homebound. In the UK, there is anexample of a rheumatology clinical nurse service that pro-vides primarily emotional, psychological, and social sup-port to patients in the community (8). The Mental HealthOutreach Program for the Homebound Elderly at Colum-bia-Presbyterian Medical Center Department of Psychiatryin New York City is a good example of a rare multidisci-plinary team for homebound elderly adults with psychiat-ric illness. The team is comprised of a psychiatrist, aninternist, social workers, nurses, health aides, and a phys-ical therapist. They provide a comprehensive service ofinitial assessment, acute intervention, case management,and ongoing treatment (9).

There are also cases in the literature of mobile dentistswho make home visits, primarily for the elderly popula-tion in the New York City, Boston, and rural areas. Again,

there are no established medicine subspecialists that com-monly make house calls.

Therefore, this pilot program highlights the role of arheumatologist in caring for the homebound. Much of theexisting data regarding the extent of musculoskeletal dis-ease in the US come from rural settings (10). However, asthis pilot study shows, urban areas in this country willalso have an increased incidence of homebound patientswith rheumatic diseases. An important idea to rememberis that patients are homebound not from their underlyingdiabetes mellitus, hypertension, or renal insufficiency, butoften their musculoskeletal incapacities, psychiatric ill-nesses, and social environment keep these patients athome. Of all subspecialists, visiting rheumatologists areespecially needed for this reason. Often, the skills thatrheumatologists use are portable; they rely heavily on clin-ical history, physical examination, and procedures, all ofwhich are transportable. For example, one can easily carryneedles, syringes, steroids, and lidocaine for intraarticularinjections, arthrocenteses, bursitis injections, or bursadrainages. Visiting nurse services can be used to help withblood draws for laboratory work and injectable medicationadministration, and portable home radiograph servicecompanies can be employed for imaging.

The RAPID3 score was used to provide an objectiveclinical assessment of a patient’s disease activity acrossdifferent rheumatic diseases (7). The average RAPID3score on initial evaluation was greater than 20 in thispopulation, reaffirming the great need for treatment andintervention in this hidden subset of the population. In thefuture, comparisons of RAPID3 scores before and afterinterventions will be an important aspect to study.

Educational opportunities to teach fellows, residents,and medical students about rheumatic diseases that areoften at later stages than are seen in the clinic setting, aswell as performing procedures, is an important part of thisinitiative. Targeted pain control has also been a significantpart of this program, for example, giving a patient with RAa brief course of prednisone instead of narcotics for flareswhen synovitis cannot easily be assessed by a PCP.

During the course of the year, several barriers were en-countered that are not always apparent in the clinic set-ting. Patients were resistant to medications initially, and itoften took time to establish a trusting relationship with anew physician caring for patients in such an intimatesetting as their own home. Finally, since homebound pa-tients tend to have much lower functional status comparedwith those patients that are able to make it to outpatientappointments, goals for improvement were tempered andfocused on quality of life and pain control.

Fifty-seven home visits were made in this study period,and since the end of this pilot program, there have been anincreasing number of consults. The fellowship curriculumwill possibly allow more days to make home visits in thefuture, as there is currently a waitlist for new patients to beseen in their homes. However, this will have to be bal-anced with a busy inpatient consult service as well asoutpatient clinic days. Also, given the nature of seeingpatients in the home, travel times from one place to an-other decrease the number of patients that can be seen inone day. It is important to remember that the seemingly

1484 Jain et al

small number of patients seen in their homes in this pilotstudy does not devalue the experience of each patientvisit. Furthermore, it highlights a commitment to commu-nity service that is not commonly incorporated into anacademic fellowship program. Evaluations by fellows, stu-dents, and residents after patient encounters have beenpositively received.

In terms of the cost assessment of a home visit by aconsultant, Medicare, Medicaid, or commercial insurancefor the house call and procedures can be billed and thereimbursement is comparable to a regular office visit.Home visits can be a viable option in that they are reim-bursable by insurances, reach an underserved and moreseverely ill population, and can save the larger healthsystem costs by preventing avoidable emergency room vis-its, hospitalizations, and ambulance transport to an officesetting. The costs to the practitioner would be travel andtime, but these can be mitigated by scheduling visits closeby or designating time in an office practice setting to groupas many visits together as possible.

In conclusion, the ongoing rising number of consults,the nature of consults, and the extent of disease on theinitial evaluation of these homebound individuals high-lights the importance of a subspecialist role in patientvisits in the community, and especially by rheumatolo-gists. This initiative underscores the presence of a hiddenpopulation with unmet needs and defines our role in pa-tient advocacy consistent with our goals and beliefs asphysicians and as rheumatologists.

AUTHOR CONTRIBUTIONS

All authors were involved in drafting the article or revising itcritically for important intellectual content, and all authors ap-proved the final version to be published. Dr. Jain had full access to

all of the data in the study and takes responsibility for the integ-rity of the data and the accuracy of the data analysis.Study conception and design. Jain, Soriano, DeCherrie, Kerr.Acquisition of data. Jain, Dasari.Analysis and interpretation of data. Jain, Kerr.

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