For Patients, No Place Like Home : Hospitals, Visiting Nurse Assn. in Cooperative Effort
After 62 years of living in the United States, 84-year-old Dora Goldman is still very much the proper Englishwoman. Surrounded by family photos, plants and whatnots, Goldman is in her element as she serves afternoon tea to a visitor.
But there is something unusual about this scene.
In the kitchen a small table is heaped with medication bottles, and on the living-room floor, boxes are overflowing with medical supplies. While Goldman orchestrates the tea, she’s hooked to an i.v., and her visitor is Nancy Miller, the public-health nurse who calls on her every day.
Goldman and Miller are part of a home-care program begun last September by UCLA Medical Center and the Visiting Nurse Assn. of Los Angeles, one of two contract-based relationships between hospitals and home-health agencies in Los Angeles. (Cedars-Sinai Medical Center has a similar agreement with the Visiting Nurse Assn.)
The UCLA program allows patients who can to leave their hospital beds and return home to recuperate from illnesses, or like Goldman, live with chronic medical conditions with the help of nursing house calls.
Goldman has cardiomyopathy, an enlargement of the heart affecting its ability to adequately circulate blood, causing fluid to build up in her lungs and legs. She also has severe arthritis, and uses a cane to walk from one room to another.
Several times a year, she is admitted to UCLA Medical Center for congestive heart failure. In the hospital, her fluid intake and medication are monitored, but when the condition has stabilized, she goes home.
Miller visits daily to administer a diuretic--to keep Goldman’s body fluids down--and minerals such as potassium to replace those lost when the diuretic takes effect. She also checks Goldman’s weight, blood pressure, and the skin around her calves and ankles where sores break out due to her circulatory problems.
Goldman has a Hickman catheter, a tube that has been surgically implanted into her heart through which Miller administers Goldman’s daily injections.
Although the daily procedure, which takes about two hours, tires her, Goldman prefers having it done at her apartment in Los Angeles to living in the hospital. “This is where my husband died; I don’t want to move,” Goldman said. “When my children come, they have somewhere to stay. Wherever mother is, that’s home.”
Goldman is one of about 200 discharged patients UCLA home-care program coordinators handle each month, about one-tenth of the total number of discharges, said Charlene Vener, a social worker and the program’s manager.
In addition to the elderly, the program’s outpatients include heart attack, stroke or AIDS victims, head trauma cases or individuals with spinal-cord injuries, Vener said.
A variety of pediatric services are also available, including care for children referred by consultants from the hospital’s Suspected Child Abuse and Neglect team, liver and heart transplant patients, babies from the neonatal intensive care unit and post-accident or trauma victims brought to the hospital on Med-Star, the center’s emergency helicopter.
Must Be Homebound
A patient must be homebound, under a physician’s care and in need of intermittent care to be considered for the program. Some patients in the program also require sophisticated equipment such as ventilators, oxygen or intravenous feeding catheters and supplies.
Nurses, physical therapists and social workers from the Visiting Nurse Assn. provide intermittent skilled nursing care, wound care and help with high-tech services such as monitoring infants at risk of Sudden Infant Death Syndrome.
The program’s office is staffed by Vener and three discharge coordinators from the Visiting Nurse Assn. Home-care nurses come from the association’s pool of more than 650 full- and part-time employees.
A patient is referred to the program by the attending physician, or by a nurse or social worker. A coordinator determines the feasibility of home care after talking with a patient and his family and assessing what the home setting is like. If a patient needs to learn how to operate medical devices, nurses begin such training in the hospital and do follow-up training with the patient at home.
The Visiting Nurse Assn. provides intermittent care, medical services not needed on a round-the-clock basis. If 24-hour skilled nursing care or other services are required, the association offers appropriate referrals.
Either private or government health insurance covers most of the cost of home care. Goldman’s medical supplies are paid for by Medicare, the federal government’s health insurance program for patients over 65 year old, but her family picks up the tab for intravenous medications, which Medicare does not cover. Goldman worries that this expense is costing her “every penny I have” and putting a financial burden on her two sons and daughter. But she would rather live at home with the extra costs than stay hospitalized, she said.
About 50% of the patients in the home-care program are covered by Medicare, Vener said. Medi-Cal, California’s version of the federal health insurance program, and private insurance cover costs for some patients. But if a patient hasn’t got money, “We won’t say no,” said Mar Preston, spokeswoman for the Visiting Nurse Assn., which handles billing insurance companies for all home-care patients.
UCLA contracted with the association rather than establish and staff its own home-health nursing agency due to cost constraints, among other reasons, Vener said.
The association is one of the nation’s largest nonprofit home-health nursing organizations. In 1985, association nurses from eight area offices made 200,000 home visits to more than 13,500 patients in Los Angeles County and in southern Kern County.
Doctors, nurses, pharmacists, therapists and quality assurance experts on three different task forces are examining how UCLA could expand its home health-care activities, according to Vener. UCLA does not provide medical services for home patients at present.