Robert’s Story

With permission to share his first name, Robert, a war veteran who lives on his own, fiercely independent, a homebound senior being followed by Dr. Ron Ordona, DNP, FNP-BC (a Nurse Practitioner at Senior Care Clinic House Calls).

Read more of Robert’s Story in United Health Foundation “America’s Health Rankings” blog.

Ron Ordona, DNP, FNP-BC, of Senior Care Clinic in Lincoln, Calif., is one of a team of clinicians who make medical house calls to patients like Robert – a Vietnam War veteran who lives alone in an RV at a mobile home park. “He is fiercely independent,” Ordona says of Robert, “but he has COPD, is oxygen dependent, has PTSD and suffered multiple surgeries and falls.” Ordona says Robert fits many of the categories linked to social isolation in seniors. Living alone is a well-documented risk factor for social isolation – those who live alone are more likely to have difficulty socializing with others and may experience loneliness. Further, life events such as retirement, loss of loved ones such as a spouse or friends, and age-related physical changes and possible cognitive decline can make it difficult for seniors to maintain social connectedness.
Effective interventions to prevent and address social isolation will be increasingly important to public health with the growing older adult population. When Ordona visits Robert, “it takes him some time to recognize me but once he gets acclimated he recalls and calls me as ‘Dr. Ron.’” Robert says, “I kid Dr. Ron and he kids me. I don’t go anywhere; I just stay in my home and watch TV so I really like it when he visits.”

“I get visits two or three times a month,” says Robert. “It’s really nice. They do their health checks and I like to talk to them.”

Rising to the Meaning of Easter

“Little changes, like little efforts, can start to make a difference in (someone’s) world.” A quote adapted from Janine di Giovanni, an American journalist.

A house call where and when it matters…

He was a Vietnam War Veteran (I’d say a hero in his own right). He lives in an old RV. And fiercely independent (to a fault). Although his family lives within the area, he has preferred to be independent and continue to live on his own.

Today, Saturday before Easter, I had the privilege of doing a house call visit, serving one of our honored veterans for a Transitional Care Management visit. He has just been discharged from a skilled nursing facility and has been home a few days but his appointment with his primary care provider is not until a number of weeks and he was running low on his medication refills (which included refills for inhalers for his COPD).

This is a house call where it matters. And when it matters. This is what fuels those of us in the Home Based Primary Care practice to do what we are passionate about– providing access to care for those who are homebound and vulnerable. This is such a rewarding aspect of medical house calls. He could have ended up in the ER just because he could not get his medications (inhalers) refilled in time.

Not an actual patient.

In touching the life of this gentleman, albeit for a short and fleeting while, he teaches me the value of standing on one’s own feet and keeping the dignity of existence despite the humble dwellings.

A Vietnam War Veteran who is fiercely independent and wants to remain so…

It also made me realize how access to care is so important for homebound seniors. Those that have been there before us, those (like this war veteran) who have given their all, so the rest of us can enjoy the freedoms that are in front of us today.

In keeping with the season and in anticipating the celebration of Easter, I give honor to this my homebound patient for teaching me humility and gratitude for much of what life has to offer.

According to Dr. Thomas Cornwell of the Home Centered Care Institute, home-based primary care practices are a viable solution to addressing quality of care and significantly reducing costs for the healthcare system. Just imagine what a visit to the ER would cost as compared to a preventative house call visit. But most importantly, just imagine how much stressful it is going to be for an elderly person to have to be transported to the ER mainly for a preventable reason (such as a refill of his prescriptions).

Easter is meant to be a symbol of hope, renewal, and new life.

-Janine di Giovanni

Polypharmacy Reduction in Transitions of Care: ER/Hospital Readmission Prevention

Presented by Dr. Ron Ordona, DNP, FNP-BC to CANP 42nd Educational Conference in San Diego, CA, March 17, 2019.

Dr. Ordona presenting to NP-attendees at the 42nd CANP Educational Conference in San Diego, CA.

Vulnerable, homebound older adults (>65 yo) are highly susceptible to unplanned 30-day hospital readmissions. These events are stressful, both physically and mentally for patients, families, and caregivers alike resulting in dissatisfaction with care. Anytime an elderly person gets admitted and readmitted to the hospital, functional decline sets in, delirium is commonplace, worsening dementia occurs, and, more often than not, results in polypharmacy for the elderly.

On the other hand, the readmission of our elderly patients is costly for the healthcare system. So much so that Medicare has instituted the payment reduction for excessive readmissions. In the first year of the Hospital Readmission Reduction Program, 2,200 hospitals received cumulative penalties of $280 million.

What is Polypharmacy? Masnoon, et al, from a systematic review, defines polypharmacy as a numerical definition of five or more medications. Polypharmacy increases the risk for adverse drug events (ADE) especially in the elderly.

Adverse drug events (ADE) is harm experienced by a patient as a result of exposure to medication. According to the US Food and Drug Administration (FDA), 2 million ADEs occur annually, causing 124,000 deaths per year. Sixty percent of these events are ADEs and preventable.

Medication reconciliation and the determination of medication appropriateness need to happen throughout the healthcare continuum. In the transitions within facilities such as the hospital, such as from intensive care units to the acute care units. Between healthcare facilities such as from the hospital to skilled nursing facilities (SNF), and finally from health care facilities to home or places of residence such as assisted living facilities (ALF).

Deprescribing is the process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes. Deprescribing is not without its barriers. According to a study published in JAMA, lack of knowledge may be a factor. For example, 39% of providers were not aware that tight glucose control could harm the elderly. Other factors include fear of a bad report card (42%), fear of legal liability (25%), and not enough time to discuss deprescribing plans (30%).

There are deprescribing tools available for providers. One of which is the Good Palliative-Geriatric Practice Algorithm (GPGP). In this algorithm, the goal is to stop drugs that are unnecessary or are duplicative. Shift to safer, less costly or non-pharmacologic alternatives. Finally, simplifying the dosing, scheduling or substituting one for two.

Deprescribing tools include Good Palliative-Geriatric Practice (GPGP) Algorithm.

In the end, “the tool does not rule.” We look at our patients and see what works for them and to never lose sight of the individual person.

References (full list available upon request).

  • Hamar, et al, 2016; Stall, et al, 2014; Towne, et al, 2014; Levine, et al, 2012
  • Walker, et al, 2007; Ahmed & Pearce, 2010; Mramor, et al, 2015
  • US Food and Drug Administration
  • JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324 Published online March 23, 2015
  • JAMA Intern Med. 2015;175(12):1994-1996.doi:10.1001/jamainternmed.2015.5950
  • Garfinkel, et al, Arch Intern Med 2010, 170 1648-1654
  • Masnoon, et al. (2017) What is polypharmacy? A systematic review of definitions. BMC Geriatrics, DOI 10.1186/s12877-017-0621-2

Annual training for Care Home By RNs staff

The purpose of training is to tighten up the slack, toughen the body, and polish the spirit. (Morihei Ueshiba – Japanese Athlete, 1883-1969)

Care Home By RNs staff gets standard annual physical and lab draw. Staff has the option to get more tests done if they so chooses.

Each year, Care Home By RNs staff get training and refresher course on caring for our elders.

Staff also gets complimentary annual lab draw and physical exam performed by Senior Care Clinic House Calls and courtesy of Care Home By RNs.

The greatest gift you can give your family and the world is a healthy you. (Joyce Meyer, American Author).

Patients With Heart Failure More Likely to Get Readmitted to the Hospital

by Anquinette Cray and Ron Billano Ordona

The at-risk population is the older adult 65 years and older, homebound, with congestive heart failure (CHF).

Patients with heart failure are five times more likely to get readmitted.

They are at greater risk for emergency department (ED) visits or hospital admissions and readmissions. According to our quality improvement project results (Ordona, 2018), homebound seniors with CHF are five times more likely to be readmitted to the ED/hospital.

This is associated with greater use of health resources, morbidity, and mortality (Yang, Ornstein, & Reckrey, 2016). The Centers for Disease Control and Prevention (2016) estimated there are six million adults in the United States with heart failure. The national healthcare cost is approximately over $3 billion. CHF also diminishes the quality of life by 80% for individuals over the age of 65 (Punchik et al., 2017).

The aggregated statistical data of the risk factors, according to the American Heart Association (AHA, 2017), states that in 2010 the estimated cost of heart disease was $863 billion globally and is expected to rise to $1 trillion.

Linking these individuals to needed resources such as education, planning, social support, and community resources can improve this population group’s quality of life. Cardiovascular disease and its risk factors affect patient independence.

According to the AHA, coronary heart disease results in 45.1% of deaths in the United States, followed by stroke 16%, heart failure 8%, and hypertension 9%.

The vulnerable population may have a lack of instrumental support, neighborhood, and community resources. Multiple chronic conditions associated with coping, diminished social support, and a sense of loss of control increase the stress of life.

Transitions into the community is important. Care Home By RNs partners with Senior Care Clinic House Calls to help prevent unnecessary trips to the ER.

Note: Ms. Anquinette Cray, MSN, NP-C is working on her Doctor of Nursing Practice (DNP) project with Grand Canyon University, an offshoot from Dr. Ordona’s previous work on transitional care medical house calls for homebound seniors. Ms. Cray aims to measure perception of home health nurses in caring for homebound seniors during transitions of care in collaboration with the nurse practitioner implementing transitional care medical house call visits.

Dr. Ron Billano Ordona, DNP, FNP-BC is the Gerontological Advanced Practice Nurses Association (GAPNA) Housecalls Special Interest Group (SIG) chair. The SIG meets remotely via telephone/videoconference every first Thursday of the month at 5:30 p.m. (Pacific).

Read more on GAPNA website.


  • Allen, J., Hutchinson, A.M., Brown, R., & Livingston, P.M. (2018). User experience and care for people transitioning from hospital to home: patients’ and carers’ perspectives. Health Expectation, 21(2), 518-527. doi:10.1111%2Fhex.12646.
  • American Heart Association (AHA). (2017). Heart disease and stroke statistics 2017 at-a-glance. Retrieved from…
  • Centers for Disease Control and Prevention. (2016). Interactive atlas of heart disease and stroke. Retrieved from
  • Meleis, A.I. (2010). Transitions theory: Middle range and situation specific theories in research and practice. New York, NY: Springer Publishing Company.
  • Ordona, R. B. (2018). Transitional care medical house call: A pilot project. Boise State University Repository. Retrieved from
  • Punchik, B., Komarov, R., Gavrikov, D., Semenov, A., Freud, T., Kagan, E, Goldberg, Y., & Press, Y. (2017). Can home care for homebound patients with chronic heart failure reduce hospitalizations and cost? PLoS ONE, 12(7). doi:10.1371/journal.pone.0182148
  • Yang, N., Ornstein, K., & Reckrey, J.M. (2016). Association between symptom burden and time to hospitalization, nursing home placement, and death among the chronically ill urban homebound. Journal of Pain Symptom Management, 52(1), 73-80. doi: 10.1016/j.jpainsymman.2016.01.006

Celebrating 2019 with Care Home By RNs Staff

“Collaboration is a key part of the success of any organization, executed through a clearly defined vision and mission and based on transparency and constant communication (Dinesh Paliwal).”

Care Home By RNs staff take time out to celebrate each other.

We beam with pride in having staff who’s been working with us for 6 years or more, as well as new ones who infuse new energy to our organization. Some of our staff has moved on to become RNs, LVNs, Radiology Tech and others. Some are currently in school for professional degrees. We are blessed to be in collaboration with such talents. We look forward to continued mutually productive year 2019!

Thanks to the leadership of Yas Patawaran, operations manager, who handles the day-to-day hustle and bustle, in partnership with team leaders Christina, Manny and Daniel.

We also acknowledge Albert Wilson for being the group’s frontrunner for families and community partners.

Thank you everyone for 2018 and here’s to another mutually productive year 2019!

Polypharmacy and the Readmission Quagmire

Our homebound seniors belong to a growing population group that is vulnerable including unnecessary trips to the ER or hospital. When we implemented a quality improvement project looking into homebound seniors discharged from skilled nursing facilities, we found that more than. half of these seniors come home with 11 medications (the systematic definition of polypharmacy is 5 or more active medications).


By doing transitional care medical house call visit, we were able to significantly reduce polypharmacy to 7 medications. Polypharmacy is one of the quicksands in preventing readmissions to the ER or hospital.

Dementia and the Brain

The portion of the brain that gets preserved, according to Mary Cochran Abraham, GNP, in her presentation to the California Association of Long Term Care Medicine (CALTCM) this fall, includes the areas that control automatic speech and rhythm (circled in blue above). This explains why music can be an integral part of a dementia patient’s comprehensive care plan. It also explains why some of our dementia patients repeat words such as, “help me, help me, help me,” or repeats expletives over and over. 

Emergency Preparedness in RCFEs

AB 3098 is effective January 1, 2019

We cannot stop natural disasters but we can arm ourselves with knowledge: so many lives wouldn’t have to be lost if there was enough disaster preparedness (Nemcova).

AB 3098 was recently signed by Governor Brown, effective January 1, 2019. This bill requires all RCFEs to have additional elements within the emergency and disaster plan. 

… Care Home By RNs has geared up to meet this requirement.

A Picture is worth a Thousand Words

Conducting a fire drill at Aspen Meadows Care Home By RNs in Lincoln, Ca headed by Christina (house manager) and assisted by Mary Ann.

This bill requires all RCFEs to have additional elements within the emergency and disaster plan. In addition, this bill requires Community Care Licensing to confirm, during annual visits, that the emergency and disaster plan is on file at the facility, with required content. Violation of these provisions would be a crime.

Disasters in 2017

The year 2017 was a record year for disasters. Preparation is key, according to the Senior Community Learning.

More information about disaster preparedness can also be found in including disaster toolkits.

Look deep into nature, and then we will understand everything better… (Albert Einstein)

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Caring in extraordinary circumstances

by Albert Wilson, RCFE Administrator (excerpts from a letter to state licensing)

As most of us probably notice, the hospitals of today are looking more like ICUs and so consequently the skilled nursing facilities (SNFs) are looking more like the hospital of years ago. Consequently, the Assisted Living Facilities including those of us who are in the 6-bed healthcare space are also seeing this change in the types of clients that are being referred to us.

PEG tube may be a way to continue nutrition when a person is unable to eat by mouth.

For example, we had three separate requests for PEG tube care in the last week alone. We let the families and discharge planners know we will work on developing a strategic care plan that will help address these needs. As we know, some of these PEG tube clients either do not have enough funding to afford SNF care at private pay or just are not able to thrive in a large-scale care environment that a focused care environment (that small homes) can provide may benefit them.

A reducted approval letter for PEG tube care at Care Home By RNs facility.  CONFIDENTIAL: Pls do not copy, print or distribute.

To worsen matters, some of our seniors are either clogged up in the hospital ERs or SNFs that worsen the hospital/ER readmissions problem. 

At Care Home By RNs, we are hoping that we would be able to meet licensing requirements and regulations (through exceptions) to take care of clients with PEG tubes in a small home-like environment. It’s been rightly told to us that regulations show PEG tubes are outside the scope of RCFE’s.

Care Home By RNs is continuously working on innovations in the care for seniors in the 6-bed residential care realm. A program/action plan in collaboration with a medical house call practice who can provide the medical and nursing oversight may be able to make the care in this extraordinary circumstance be a reality.

We have had success in getting an exception granted in a Care Home By RNs facility in the Bay Area. We’re open to new ideas on how to move forward now or in the near future to find a way to serve our community and families in need of PEG tube care.