Youngstown State graduate helps geriatric team give care via house calls
PITTSBURGH — Jacqueline Blessitt has been unable to communicate with words ever since vascular dementia robbed the Braddock resident of speech a few years ago. Still, nurse practitioner Jacqueline Cullen can tell when the 95-year-old doesn’t like a certain medical procedure.
She also knows how to calm her patient so she can complete it.
“We have to clean out those ears!” Cullen, 33, cheerily warns her after an otoscope exam reveals impacted earwax during a recent visit to the house the nonagenarian shares with her daughter, Patricia Blessitt.
Earwax blockage can happen at any age. But it’s particularly prevalent in aging adults, Cullen explains, because the waxy substance doesn’t migrate out of the ear canal as easily. Removing it is critical because hearing loss is the most modifiable risk factor for developing dementia.
“Hearing helps you understand and be more present,” she explains. “And for Patty,” she adds, shooting her a conspiratorial smile, “it means not yelling in her [mother’s] ears so much!”
After wrapping a towel around her patient’s neck, Cullen fills the ear irrigator she pulled out of her nursing bag with warm water, softly places her hand on Blessitt’s cheek and gently squeezes the bulb, releasing water into the ear. Throughout, nurse practitioner student Kelly Drummond holds the senior’s hands in support.
“I know, it feels funny,” Cullen says sympathetically when Blessitt moans and squirms in her wheelchair.
She moans again when Cullen repeats the process after a lighthearted “1-2-3-water!” and then scrapes out the impacted wax with a curette. Blessitt’s grimace doesn’t go unnoticed.
“Sorry!” Cullen apologizes. Then, gently patting her shoulder, she adds: “You’re going to hear better, though.”
Reviving an old practice
About 244,000 people 65 or older live in Allegheny County, and of those, nearly a third live alone, according to the most recent American Community Survey data. The Pittsburgh metropolitan area, in fact, is home to the country’s largest share of retirement-age residents who have lived in the same house for more than 30 years.
Getting to the doctor’s office for a regular checkup or ongoing care can become more difficult for many of these residents because of mobility problems or issues including dementia.
For the homebound — defined by Medicare as someone unable to leave home unassisted — it can be impossible. In Blessitt’s case, for example, being in a wheelchair without a working outdoor lift is a major obstacle.
Yet seniors are more likely to get diseases such as cancer, heart disease and osteoporosis diabetes, and small changes like age-related loss of muscle mass or hypertension can be detrimental in the elderly, says Cullen.
“You have to be more mindful of medication, along with visual and hearing changes and depression — things you don’t worry about when you’re young but can influence your health as you grow older,” she says.
For homebound patients, keeping an eye on things is especially important because if a visiting nurse or doctor can’t provide care, an issue could become so serious they end up in the hospital. And for many families, “The goal is to keep their loved ones at home,” she says.
Cullen and other geriatric primary care providers and specialists within Allegheny Health Network Primary Care Institute’s Division of Geriatrics are dedicated to helping these seniors remain independent by making house calls every three to four months through a home visit program. Insurance and/or Medicare covers the cost the same as an office visit, so long as there is a demonstrated medical need.
“We’re giving care to people who need it but can’t access it easily” and whose health is best when they’re in a familiar place with their families, says its director, Lyn Weinberg, a geriatrician for 10 years.
The program isn’t new; though limited, home visits have been available in one form or another for at least 20 years as part of the West Penn Allegheny Health System (now Allegheny Health Network), says geriatrics division manager Jessica Williams. Nor is it unique to AHN, as primary care physicians will sometimes visit an established patient at home.
“We’re just organized around it,” says Weinberg.
After scaling back during an earlier period of the COVID-19 pandemic, the home visit program is once again growing to where it now includes two doctors, five NPs and three RNs — and a patient roster of about 40.
“It comes from a compassionate place that’s very intimate,” says Williams. “It’s amazing to be able to help these families along the way and see them through to the end.”
Autonomy and independence
Cullen didn’t originally plan a career in nursing, even though her family always told her she’d be good at it due to her caring nature; her first job after graduating from Youngstown State in 2011 with a biochemistry degree was as a pharmacy assistant. But she soon realized she’d rather work bedside than in a lab and went back to nursing school.
Shadowing a doctor during her undergrad days, she got to see the hands-on care nurses provide patients and how they stand by their side. “And I knew that’s what I wanted to do.”
After graduating from nursing school in 2015, she worked for two years in a Cleveland hospital in trauma. A job in West Penn Hospital’s medical ICU followed after moving to Pittsburgh with her wife, Marissa, in 2017. “It was intense,” she says, “but I wanted to do something different.”
While she did love bedside nursing, Cullen wanted to further her education. She also wanted a job with more regular hours. So in 2017 the Highland Park resident enrolled in Carlow University’s master’s of science in nursing program, with the goal of becoming a family nurse practitioner. Unlike RNs, NPs can prescribe treatments, order tests and diagnose patients.
“I wanted more autonomy and independence,” she says, along with the ability to think critically and make decisions.
She decided to specialize in geriatrics because she’s always had an affection for older people and feels there needs to be more awareness, responsibility and dignity for them at the end of life.
“It’s definitely an underserved population,” she says.
Geriatrics, in fact, wasn’t even a specialized field until the 1970s. Even today, most health professionals would rather go into more “glamorous” or exciting specialties like women’s health, pediatrics or oncology — despite the fact the number of Americans 65 and older is projected to reach 89 million by the year 2050, according to Washington, D.C.-based Population Reference Bureau.
Because most older patients have a lot of medical problems that require ongoing care and multiple medications, geriatricians must take a “global picture” of a person’s health. That requires additional training that doesn’t translate into higher salaries, says Weinberg; geriatric specialists are among the lowest-paid physician specialties in America.
“And there aren’t a lot of incentives for doctors and medical students,” she says.
As such, the demand for geriatric specialists always will exceed the capacity; the U.S. only has about 8,200 full-time practicing geriatricians, according to the nonprofit American Geriatrics Society.
The field’s complexity — along with a self-described “soft spot” for old people — is what drew Weinberg, 40, into geriatrics a decade ago. While the limiting nature of a house call can be challenging, it can also be rewarding because it often aligns with the goals of the patient.
“They don’t want complicated or aggressive care,” she says. That, in turn, allows her and her staff to rely on old-fashioned clinical skills like history-taking and physical exams. “I can be a real doctor. I’m not ordering a lot of tests or staring at a computer. We can keep care basic and [focus on] what’s important to them.”
“Just because they’re homebound doesn’t mean they don’t have quality of life,” adds Cullen. “I wanted to work to change the stigma that just because you’re getting older you should feel a certain way.”
Old, but still resilient
Of the 40 or so patients in AHN’s home visit program, Cullen will see three or four at home each Tuesday, sometimes as far away as Tarentum or New Kensington; the rest of the week she’s in the office. Visits take about an hour and include the same procedures as an office visit — a full physical exam, blood and urine work, ear cleaning and general wound care. If required, she also can order X-rays or ultrasounds in the home. A nurse does follow-up care once a week.
Many have dementia but she could also see someone with Parkinson’s or congestive heart failure, who is quadriplegic, uses a wheelchair or has severe degenerative bone disease and can’t walk.
In terms of medical conditions, it’s often sad because you wish you could do more, she says. But it’s also rewarding to have patients who, despite being in their 80s or 90s, are living the best-quality version of life. That’s because their health care provider sees them as a whole person rather than just an age.
“And the things they’ve lived through,” Cullen exclaims. “They’re so resilient and get overlooked because they’re old. But they still have so much to offer.”
What makes her the most sad is when patients are lonely or don’t have a strong family or support system.
About 27% of Americans 65 or older lived alone in 2021, per a report from the Administration on Aging.
“It’s really humbling to see how some people are alone,” she says with a sigh.
Also on the downside: She can’t always see patients the day or even week they need her, and because she’s working alone out of a nursing bag, she doesn’t have access to all the equipment in the office or support of medical assistants.
“When it’s just me by myself, I have to deal with whatever I walk into,” she says, adding, sometimes “it’s a MacGyver thing.”
There also are the physical restraints of working with someone who is bed- or wheelchair-bound. Cullen recalls helping a patient use the toilet in a bathroom so small, she had to “get creative” and stand on the back of the commode to lift the patient out of the wheelchair and onto the seat.
“It can get a little interesting,” she says with a laugh. “But then you feel so good!”
‘No better feeling’
Cullen first saw the woman she affectionately refers to as “Miss Jackie” three years ago in the Bloomfield office, when the then-92-year-old lived in a nursing home. She took her nursing bag on the road two years ago, when the home closed and Blessitt had to move back into her daughter’s ranch house atop a steep set of stairs in Braddock.
As her mom’s primary caregiver, Patricia Blessitt, 67 — who retired from the foster care agency A Second Chance nine years ago — acts as the nurse practitioner’s ears and eyes between visits, answering questions that give clues to her health such as, “how is she sleeping,” “is she still eating,” and “how’s her skin?”
“How’s my girl?” Cullen asks when she walks into the house on a recent Tuesday. Dressed comfortably in a bright-pink pullover and flowered stretch pants, Blessitt is sitting in a wheelchair, her long gray hair pulled into a tight braid. She’s humming and rubbing her forehead, signs she is agitated.
Still, she smiles when Cullen places an arm cuff above her left elbow to take her blood pressure, but then gives her a side eye coupled with a groan when she inflates it.
When it’s time to listen to her heart and lungs, Patricia has to urge her mother to take a deep breath while Cullen holds her hand.
When oldest daughter Diane Thompkins of Penn Hills arrives a bit later, Cullen goes over Blessitt’s list of medicines and offers the name of a podiatrist who makes house calls. Their mother has lost a little weight since her last visit, and she’s also more fatigued and irritable — a common symptom for people with memory loss who suffer from “sundowner’s syndrome.”
“I can just look at her face and tell,” says Patricia.
But for someone who will turn 96 in August?
“Everything looks good,” Cullen declares. “She’s stable.”
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This story was originally published July 23, 2023 at 4:00 AM.