The Hospital Is No Place for the Elderly (2nd of 3 installments)

https://www.theatlantic.com/magazine/archive/2013/12/the-home-remedy-for-old-age/354680/

The “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.

Home-based primary care comes in many varieties, but they share a treatment model and a business model. The treatment model begins from the counterintuitive premise that health care should not always be medical care. “It’s not medical treatment, it’s helping meet personal goals,” Brad Stuart said. “It’s about ‘Who is this person, and what do they want in their life?’ ”

In Sutter’s Advanced Illness Management program, known as aim, each patient is assigned to a team of nurses, social workers, physical and occupational therapists, and others. The group works under the direction of a primary-care physician, and meets weekly to discuss patient and family problems—anything from a stroke or depression to an unexplained turn for the worse or an unsafe home.

I sat in on some of these team meetings. A social worker and a nurse talked over a case and decided they needed to make a home visit together; a doctor suggested a medication change; the various members of the group compared notes on one patient’s hospitalization while discussing whether another’s 911 call might have been averted. Strikingly, patients were presented not as bundles of syndromes—as medical charts—but as having personal goals, such as making a trip or getting back on their feet. The team tries to think about meeting patients’ goals rather than performing procedures. An advantage of the multidisciplinary approach is that over time, as clients’ conditions change, the group can recalibrate the mix of services and providers, to avoid jarring transitions. “Once in aim, always in aim,” one coordinator told a patient’s family. Over several years, a person might move from independence and occasional social-worker visits to hospice care and finally death, all within aim, and mostly at home.

One recent morning, while I was waiting at Sutter to accompany a nurse and a social worker on a home visit, the phone rang. It was a panicked caregiver whose charge had rectal bleeding. A case manager alerted the patient’s regular nurse so that she could make a visit right away, almost certainly averting a 911 call, and possibly an ambulance/ER/hospitalization ordeal. Later, in Washington, D.C., accompanying George Taler on house calls, I met a 92-year-old man afflicted with hypertension, blindness, gout, and diabetes, who had been in and out of the hospital before entering Washington Hospital Center’s home-care program in 2007, and who has not been back since—a fact that pleased him. (“I hate the hospital.”) I also met a 75-year-old woman who had recently had a massive stroke; her daughter said Taler’s program had averted at least two ambulance calls since then.

Sutter figures that the program, by keeping patients out of the hospital whenever possible, saves Medicare upwards of $2,000 a month on each patient, maybe more. The VA, for its part, says its program reduces hospital days for its patients by more than a third and reduces combined costs to the VA and Medicare by about 13 percent.

But now we come to the business model, which has been problematic. For doctors, nurses, health systems, and insurers, providing in-home service costs money. Medicare pays for hospitalization, but it does not pay for much by way of in-home care, or for social workers, or for time spent coordinating complex cases and traveling to homes and talking with caregivers. Where in-home primary care has existed, it has tended to be a foundation-funded experiment, or a charitable project, or part of a vertically integrated system like the VA, which can capture any savings. The home-care program at Washington Hospital Center runs at a 30 percent loss. Meanwhile, hospitals lose “heads in beds,” and therefore revenue. Medicare—which is to say, taxpayers—may save money, but it has no mechanism either to track savings or to pay providers and insurers for hospitalizations that do not happen.

This is why Brad Stuart was frustrated for so many years. He could see the path forward, and others could see it, but it was blocked. Today, though, he’s feeling optimistic. The path is clearing.