One of my patients called me with a high fever, chills and dropping blood pressure. He was 48 and had been a quadriplegic since he was shot during a robbery in the hardware store he owned. I called an ambulance and admitted him to the hospital, where we soon brought his urinary tract infection under control. But he developed a bedsore, which became infected with an antibiotic-resistant bacterium that breeds in hospitals. He didn't survive the hospitalization.
This was in 1998. Ever since, I have struggled to treat my patients in their homes and avoid hospitals except when absolutely necessary. I practice general internal medicine on Roosevelt Island in New York City's East River, where many of my patients are elderly and homebound: survivors of the polio epidemic, people with multiple sclerosis, paraplegics, some on respirators.
Patients who are treated at home by a doctor and nursing staff who know them intimately and can be available 24/7 are happier and healthier. This kind of care decreases the infections, mistakes and delirium, which, especially among the elderly, are the attendants of hospital care. And it is far more efficient. According to a 2002 study, for the patients treated by the Veterans Affairs' Home Based Primary Care program, the number of days spent in hospitals and nursing homes was cut by 62 percent and 88 percent, respectively, and total health care costs dropped 24 percent.
I had one 83-year-old patient whose arthritis kept her from moving around, but she loved to talk about her career as a rocket scientist — working on weather rockets, not military ones. One day, a well-intentioned neighbor dropped by and called 911 after finding her feverish and dehydrated from diarrhea.
My patient had never been treated before at the hospital she was taken to, and as a Russian immigrant, had no family here for the hospital to contact. She became disoriented; the hospital assumed she was demented and transferred her to a nursing home. It took me two months to track her down and many more to get her home, where, among well-known attendants and friends, she became lucid again. If she had lived out her days in an institution, she would have cost Medicare a great deal of money, and her life would have been shorter and far less happy.
All too often, ambulances take people to the nearest hospital, not to the one where their doctor is on staff. State laws make it difficult to administer simple treatments in the home. Emergency rooms want to admit patients, and hospitals want to discharge them to nursing homes, rather than send them home.
The good news is that last year's health care reform act included provisions for the creation of Independence at Home Organizations — groups of doctors and nurses who treat patients in their homes — and incentives to make that work appealing. The organizations can invest in extra services and home visits (for which Medicare typically will not reimburse them) because they will share in a cut of the savings that result from avoiding hospital visits and expensive procedures. The program is to go into effect no later than Jan. 1.
However, Medicare is behind schedule and has not yet issued the rules or applications to begin the process. It has been focusing instead on another provision of the new law intended to deliver more efficient care, creating accountable care organizations — groups of hospitals, doctors and nurses who work together to treat patients. But Medicare should make getting the Independence at Home Organizations up and running a priority.
We have the technology. Electronic medical records can give a doctor with an iPad as much information as any institution. With hand-held machines and a few drops of blood, doctors can get test results in seconds at a patient's bedside. Portable X-ray and ultrasound equipment can be wheeled into homes. Monitors can alert doctors to any change in a patient's heart rate.
The fact that this care is possible at home means that the role of hospitals must change. Acutely ill patients who need operating rooms or intensive care will still be brought to hospitals. But they should be quickly discharged to the care of the doctors and nurses who know them best.
For too long the institutions that make up our health care system — hospitals, insurers and drug companies — have told us that "more is better": more medicines, more specialists, more tests. To rein in spending and deliver better care, we must recognize that the primary mission of many an institution is its own survival and growth. We can't rely on institutions to shrink themselves. We need to give that job to patients and their doctors, and move health care into the home, where it is safer and more effective.
