For this episode, you must first take off your white coat in addition to tying your sneakers and zipping up your sweater. I work in a hospital-based internal medicine practice that delivers primary care to homebound men and women through Manhattan. When I worked on an ambulance, I felt like the cavalry - high noon ablaze in lights and sirens, tool belt bristling with scissors, radio, and a shiny star pinned over my heart. Trauma! Baby crowning in a Buick! We sought to outpace death as if it would bow to our right-of-way by my bellowing into the microphone, "Yield to the right!"
The nursing profession has long known the value of home visits to patient care - ever since the New York Department of Public Health sent women across tenement rooftops in long skirts. Now, I trudge politely from Chinatown to Harlem with my hospital ID and a diaper bag of supplies over my shoulder. I attend to myriad woes that would end up on the cuttingroom floor of the television show Rescue 911 (although certain kamikaze cab rides might have qualified).
Science has given chronic illness a whole new meaning, and previously fatal diseases have become "status-post exacerbation of Class IV congestive heart failure" or "status-post major CVA." The average age of these patients is 83, and nearly half live in public housing. Most are referred because of compromised functional status or noncompliance with prior care. Low Karnofsky scores reflect to an aging generation severely disabled, and often hospitalization is indicated even though death is not imminent.
The home visit is a unique and valuable way to assess patients - an endoscopic Jonah into the belly of the whale. Despite multiple comorbidities, problem lists, and medication regimens, the people I visit are mothers, fathers, and New Yorkers. "Patients" are a distant second. On the visit, one can see how homes are loved as if they were castles - whether home is a single room occupancy hotel or a Park Avenue penthouse (Unwin, 1999).
All internal medicine residents at Mount Sinai spend a month with the homebound care program after their first rotation in the medical intensive care unit (Epstein, 2002; Meyer, 1997). This allows an interdisciplinary team of nurses, nurse practitioners, and physicians to show them how the other half Uves and dies. I often wonder whether the internal residents think we are slightly crazy to do this - riding elevators that have doubled as toilets - but they are happy to be out in the fresh city air.
A home visit can often explain "frequent flier" recidivism, especially when a home is so decrepit that spending a weekend on a gurney in the emergency department seems like a visit to a spa (Naylor, 2000). After opening the front door to let me in, one elderly man shuffled down a hall lit by one bare bulb. He held onto the walls, wading his four-plus edema, bare diabetic feet through orange snowdrifts of cheese-flavored snack puffs, idly kicking at a kitten playing with electrical cords. A roast on the kitchen counter had a thick white pelt of mold. His wife (who suffers from "old-timer's," he explained while pointing one gnarled finger knowingly toward his head with a wink), was sautéing a wad of rubber exam gloves on the stove.
The future of geriatric services will be challenged by the aging of the baby boom generation. The home care arena must be where medicine and nursing, humanism, and technology fuse to build a neighborhood worthy of living in. While Mr. Rogers may not live here, the city is enriched by generations of men and women who seek to live out the remainder of their lives with dignity and, perhaps, a little humor.
- Epstein, R.H. (2002, June 4) House calls: How physicians heal themselves. New York Times.
- Meyer, G. (1997) House calls to the elderly - A vanishing practice among physicians. New England Journal of Medicine, 337(25), 1815-1820.
- Naylor, M. (2000) A decade of transitional care research with vulnerable elders. Journal of Cardiovascular Nursing, 114, 88-89.
- Unwin, B. (1999). The Home Visit. American Family Physician, 60(5) 1481-1488.