House Calls, a community benefit program offered by St. Joseph Health System–Sonoma County, has been providing medical care to seniors and others in poor health throughout Sonoma County in the safety and comfort of their homes since 1996.

“Many seniors have debilitating conditions and can’t leave their homes or advocate for themselves,” says Laura Rodriguez, a nurse practitioner with House Calls. “By treating them at home, we help keep them out of emergency rooms and avoid hospitalizations.”

Rodriguez, who has been with House Calls for five years, believes deeply in her work. “The care we provide is very patient-centered,” she says. “We take into account our patients’ physical, psychological, and social health in an environment that is familiar to them. House Calls provides a phenomenal service that our elders deserve.”

The House Calls program aims to promote health, independence, self-esteem, and safety for patients dealing with limited financial resources, lack of health insurance or underinsurance, transportation challenges, impaired mobility, and cognitive impairment with an accompanying medical condition. By providing at-home medical care to seniors, the program can also prevent or delay the need for placement in a nursing home. The House Calls team consists of nurse practitioners, registered nurses, a medical assistant, and home health aides who provide culturally sensitive services. In addition, the majority of the House Calls team speaks both English and Spanish.

Services available from the House Calls team include in-home clinical assessment, diagnosis and treatment of illness, case management, and health education. Diagnoses may include – but are not limited to – illnesses such as diabetes, hypertension, stroke, congestive heart failure, and lung and kidney disease.

“Many of the patients we treat have multiple medical problems, along with social issues,” explains Kathie Myers, supervisor of the House Calls program. “After hospitalization, some patients return to homes where there is no support. They may live by themselves and in substandard housing… many are dealing with poverty and have no medical insurance. That’s where we can step in to help.”

From July 1 through December 31, 2008, the House Calls team made more than 1,000 in-home visits to 167 patients, most of whom are elderly. House Calls patients are predominantly female, and 63 percent have Medicare coverage.

“At any one time, we have between 80 and 100 active cases,” says Myers. “The team keeps close tabs on all of its patients – we don’t forget about them. We follow-up routinely by phone and in-home visits to make certain they are taking their medications and their conditions are stable. If a patient doesn’t sound quite right to us on the phone, we arrange to stop by their house as soon as possible. We know many of our patients so well because we’ve been treating them in their homes for years, and we can tell just from their voice if they have an urgent medical need.”

House Calls also arranges additional help from other agencies and programs for patients who may need it. If the House Calls team believes patients are in an unsafe environment, they can quickly refer them to such programs as the county’s Adult Protective Services. Once a month, a member of the team picks up food from Redwood Empire Food Bank to help out those patients who may otherwise go hungry, and Meals on Wheels assistance has been arranged for many House Calls patients. One patient was even referred to the Rebuilding Together program to help make repairs to her home.

“There are many frail elderly patients who might otherwise fall through the cracks if sent home from our hospitals without follow-up,” adds Myers. “We can help improve that person’s quality of life and get the assistance he or she needs to live independently and avoid hospital re-admissions.”

To learn more about House Calls or arrange for a consultation, please call