Patient Case Studies and Testimonials

Submitted by Thomas Cornwell, MD, Wheaton, IL

The same day HCP got the blood test results, they called in medication to a pharmacy that could deliver to VJ. HCP paid for all the medication through the patient assistance funds. Physician forms for medical assistance were filled out, and patient starting receiving help through medical assistance the following months. VJ was also found to have a B12 deficiency that did not respond to Vit B12 pills, and she was started on B12 shots. VJ also had a special breathing machine she needed to use at night. The tubing had been chewed by a dog and she had tried to fix it with masking tape which did not work. Through the patient assistance fund, we were able to buy new tubing. Over the next several months, VJ dramatically improved. Her thyroid level normalized and her cholesterol, blood pressure and diabetes all came under much better control. When we first saw VJ, she had not been able to leave her motel room for six weeks because of weakness and arthritis pain. Her strength has improved with the B12 shots, and her pain is under much better control, and she is now able to walk on her own. Her swelling is completely resolved.

VJ when first seen. Her whole body was swollen from not getting her thyroid medicine.		VJ much improved a couple months later. Dr. Cornwell is holding the Oxygen she had tried to repair with masking tape.
		Left is the patient six months later. Her hair lost from low thyroid has grown back in. She is able to walk again, and her swelling is resolved.

Dr. Cornwell was called out to see this 92- year-old patient in 1994 by her daughter who said she was lethargic and unwilling to eat or drink. They refused hospitalization. Upon our arrival, her temperature was 104.9.		There was no obvious source for the patient’s temperature. After the technician drew blood, Dr. Cornwell set up for a chest X-ray.
The patient’s exam and blood test results showed her to be dehydrated (BUN 97) and hypokalemic (low potassium of 2.9). While the technician developed the X-ray, Dr. Cornwell started an IV with normal saline for hydration plus potassium chloride 40 mEq.		The chest X-ray revealed a right side pneumonia, so we knew where the fever was coming from. The patient had a terrible experience in the hospital three years earlier, and the family and patient again refused hospitalization.
We added an IV antibiotic (Ceftriaxone) which lasts twenty-four hours along with the hydration IV (conveniently using picture hooks). It is not uncommon for us to care for critically ill elderly or terminal patients in the home who are at a stage where they no longer desire hospitalization.		To our surprise, this was the patient the next morning. I have been amazed at how well even critically ill elderly do when treated in their own home.

Patient MS was first seen 12/31/97 when she was 89 years old. She was bed bound/wheel chair bound secondary to multiple chronic problems including insulin dependent diabetes mellitus, congestive heart failure, emphysema, hypertension, depression, osteoarthritis, spinal stenosis, cerebral vascular accident left hemiparesis and osteoporosis. The patient had repeated emergency department visits and hospitalizations. In 1996, the patient was hospitalized six times for her multiple conditions, but showed limited improvement. Her primary care doctor recommended nursing home placement, but patient and family refused and asked if there was any other option. The primary care physician recommended HomeCare Physicians as a possible alternative.

The HCP physician saw the patient weekly until her condition improved. Over time, her medication was decreased and the patient became more coherent and aware of her surroundings. The patient’s emotional and psychological health improved as well. The HCP physician was able to perform necessary tests in the home including x-rays and blood tests. He also ordered and made arrangements for a physical therapist (PT) to come to the patient’s home for treatment. PT was able to teach the patient to get in and out of her bed and to sit in a chair. Arrangements were also made for the delivery of a motorized scooter that allowed the patient to move throughout her home.

Since 1997, the patient has only been hospitalized twice. By 1999, the patient’s overall condition had improved so significantly that she was able to undergo cataract surgery. She later was able to start going to adult day care three times a week, which was a blessing to her and allowed her family some needed respite. In August 2009, MS will turn 100 years old.

Patient seen after she had been at an adult daycare Halloween Party in 2006.

Dr. Cornwell’s family Christmas Caroling in 2006.

Most homebound patients have five or more chronic diseases.  Patient AS was a typical 78-year- old homebound with multiple chronic problems including multiple strokes, Parkinson’s disease, heart failure, high blood pressure, diabetes, atrial fibrillation, left inguinal hernia.  He could not have the hernia surgically repaired because he was considered too sick to undergo surgery.  As the table below shows in the seven months before we started making house calls to him, he had six emergency department visits and five emergency hospitalizations.  In the eighteen months we cared for the patient prior to his passing away at home, he had no emergency department visits and two elective hospitalizations.  The first elective procedure was a G-tube feeding tube when he lost the ability to swallow because of his strokes and Parkinson’s disease.  The patient got so much better, he was able to have a second elective hospitalization to repair his hernia which allowed him to be able to go back to his church family.

	Emergency Department	Hospitalization
7 months before	6	5 (emergency)
18 months after	0	2 (elective)

This was the patient when he lost the ability to swallow. We scheduled a G-tube placement, were able to do the pre-op history and physical, labs and EKG at home so he only had to go to the hospital for the procedure.		This was the patient dramatically improved two months after the feeding tube placement reading his church bulletin. Through quality primary care in the home and better nutrition, he improved dramatically. We felt he was now a surgical candidate.
		To the left, we see the patient back with his church family after having his hernia successfully surgically repaired. The mission of house calls is to improve the quality of life of homebound patients and their caregivers while reducing heath care costs. Cases like this exemplify these goals.

Submitted by Michael Wasserman, MD, Senior Care of Colorado, Inc.

Since 2001, he has had multiple hospitalizations for pneumonia, COPD exacerbations, congestive heart failure, and a variety of infections. In 2006, he was hospitalized eight times. In 2007, he spent several months in the South Pacific, but shortly upon his return in October, he was hospitalized yet again for pneumonia. Historically, he was non-compliant with coming in for return visits with his primary care physician. Often times, those missed appointments would be followed by a hospitalization. In February of 2008, he underwent back surgery twice for an infection in one of his disks. He was hospitalized yet again in May for back pain and urinary retention.

After his May hospitalization, we initiated a weekly home visit program by one of our physician assistants, under the guidance of his primary care Geriatrician. The patient has been seen weekly since that time for monitoring and ongoing evaluation. His back pain is much better controlled, as is his diabetes. He has shown no recent symptoms of congestive heart failure. He has not been hospitalized a single time in eight months.

This is one excellent example of how regular home visits in a frail elderly individual can improve their health and significantly reduce hospitalizations and health care costs. We have many other examples such as this that we would be happy to share.

Submitted by C. Gresham Bayne MD, San Diego, CA

The Mother is not a “victim” and seeks solutions rather than compassion or someone to listen to her problems. She is intimate with all phases of American healthcare and is a strong advocate for the role of the physician in the home. An example of her statement would include having a Groshong catheter inserted as an outpatient in the ER for IV seizure medications and being faced with a high fever and no catheter instructions 24 hours after being sent home. With a portable cxr, blood work at the POC and a housecall, all on a Friday night, the doctor was able to treat the acute bronchitis rather than assume catheter sepsis, thereby preventing removal of the catheter and subsequent hospitalization.

Today, James has a significant expressive aphasia, but enjoys his life with his family and paints rather attractive paintings, some of which hang in the doctor’s office. The total cost of his care the past two years is under $15,000. To my knowledge, he has not been admitted to the hospital in years, even though they moved even farther in the rural east county section of San Diego. The current problem is that the Medicare D pharmacy supplier has unilaterally stopped his IV medications, which were the source of his stability and result of six years of trial and error due to significant allergies and technical supply problems. Communication with the Mother and pharmacy is through email, telephone and fax through the doctor’s portable computer.

Submitted by Alan Kronhaus, M.D. -- Doctors Making Housecalls, Chapel Hill, NC

At age 102, Mary B. was frail, cognitively impaired, and confined to the locked “memory unit” of an assisted living facility in Raleigh, NC, where loving family members visited her frequently. Her primary care physician was a member of Doctors Making Housecalls, and she visited the patient as medically necessary to manage Mary’s depression as well as her “mini-strokes,” hypertension and osteoporosis. The crisis that nearly killed her began on Friday, May 14th 2004. Starting as a mere trickle, blood was soon flowing briskly out of Mary’s nose, and Mary had to be rushed to the hospital.

In the ER, the physicians had to fight hard to stop the bleeding. Mary was using medication to guard against the “mini strokes” she’d been having, which made it more difficult for the ER physicians to gain the upper hand on her nosebleed. Finally, they were able to stop the bleeding by inflating in Mary’s nose the small balloon at the end of a urinary catheter. The ER physicians were going to admit Mary to the hospital, but decided to send her home later that night because they knew that her primary care physician was a member of a group dedicated to home visits, Doctors Making Housecalls, so someone could see her the next day, at home, to remove the balloon.

Back in the facility with the Foley in place, the patient became extremely agitated. By midnight, facility personnel had to call her primary care physician for help. The physician from Doctors Making Housecalls ordered Ativan, a sedative medication commonly used in the geriatric population, which calmed the patient and avoided a trip back to the ER.

The next day, Saturday, the patient’s daughter arranged for her mother’s physician to see at home and remove the balloon, as the ER doctors had advised. The physician examined the patient and noted that the “bleeding had decreased tremendously but not completely.” Because it was too risky to remove the balloon, the physician decided to wait another day and try again. She reviewed the patient’s medication to make sure that her blood thinner had in fact been discontinued, as ordered by the ER physicians, and that the Ativan started by our physician would continue to be available to the patient, should she again become agitated.

Later Saturday evening, the facility again called Doctors Making Housecalls because the patient’s blood pressure had shot up to a critical level of 180/120. Our physician treated the problem over the phone by increasing the dose of the patient’s antihypertensive, which reduced the blood pressure and again spared the patient yet another trip to the hospital.

The next day, Sunday, the physician returned to the patient’s home for another attempt at removing the catheter. This one was successful. The physician noted that the patient’s blood pressure was still elevated but better controlled, and she was now resting comfortably. She continued the blood pressure medicine at the new dose ordered the previous evening, and left detailed instructions for the staff at the assisted living facility to monitor the blood pressure closely, to reduce the chances of another nosebleed.

At a minimum, the home visit service saved three days of hospitalization, or two ER visits, for a savings to Medicare in the order of $10,000, assuming no adverse events would have occurred in the hospital or ER, prolonging the stay or requiring additional services. The total charge to Medicare for the two home visits was under $100.