Sunday, January 19, 2014

Home-Based Healthcare: The Rise of Aging in Place

William Jackson is in his third year of medical school at Stanford, doing his first clinical rotation. He is told to look into the case of an elderly man with advanced lymphoma. The patient is weak and near death; his bone marrow overtaken by cancer. The supervising oncologist has ordered a course of chemotherapy using a very toxic drug. Jackson feels certain that the treatment will kill the patient though it does not appear that the family understands this as they continue to insist on treatment. Like a buck from minor league challenging a professional athlete, Jackson appeals the decision, but a panel of doctors declines to intervene. Well, Jackson thinks, if it has to be done, I will do it myself. He mixes the drug and administers it. The patient cries, “That hurts!” A few days later, the man’s bed is empty. Jackson leaves the room with his fists clenched.

Years later, he still believes he killed that patient. Reflecting on the experience, he commented, “I was appalled by how we care for—more like, fail to care about—people who are near the end of life. We literally treat them to death.”

Here are the facts: from 1970 to 2009, spending on health care in the U.S. rose by just over 9 percent annually, creating fiscal havoc. Then in 2009, 2010, and 2011, health-care spending increased by less than 4 percent a year. Sure, the recession  had something to do with it, though several recent studies have found that the recession is not the whole story. One such study, by the Harvard University economists David Cutler and Nikhil Sahni, estimates that “structural changes” in our health-care system account for more than half of the slowdown.

In a sense, William Jackson is one of those changes. He is a leader in a growing movement of individuals who advocate for home-based care, which represents a fundamental change in the way we care for people who are chronically ill. The idea is simple: rather than wait until people get sick and need hospitalization, a multidisciplinary team visits them at home, coordinates health-related services, and tries to nip problems early.

For years, many people in medicine have understood that late-life care for the chronically sick is not only expensive but also ineffective or inhumane. For years, the system seemed impervious to change. Recently, however, health-care providers have begun to realize that the status quo is what Jackson calls a “burning platform”: a system that is expensive and inefficient. As a result, new home-based programs have started popping up in the market. Such companies and organizations have created new vocabulary in healthcare such as, “age in place” or “die with dignity”.

With his 65th birthday coming up, Jackson will soon qualify for Medicare himself. His wife wishes he would slow down, though fe refuses. “That would be like spiritual suicide right now,” he told me, “because there is so much going on. I’m more hopeful all the time. We’ve rolled the rock all the way to the top of the hill, and now we have to run to keep up as it rolls down the other side.”

Tell me: What is your perception of "aging in place" or to "die with dignity"? 

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