The ”Virtual Hospital” was a model I ran in a poor neighborhood of NYC.
We
basically targeted senior citizen city subsidized apartment buildings. Most
patients were elderly and basically have problems living their apartments for
care. Most had a care giver (family member or home aide). My team was made of
a RN (whom I can trust blindly), a pharmacist (that did home deliveries) and me.
Patients were seen at their home. After a first full evaluation which included
throwing away tons of bottles of medications (that were duplicated, old, from
multiple doctors) we got a personalize plan for the patient in conjunction with
the care giver and the RN.
The plan included self management algorithms has FS
sliding scales for insulin, weight scales for furosemide treatment for CHF, self
management instructions for COPD and asthma exacerbations and clear goal for the
patient. We promptly identified that most Hospital / ER visits for due to
medication problems or easily managed exacerbations of chronic problems.
Patient was given open access to the RN (first line of defense) that would
evaluate patient as often as needed and was in direct communication with me.
Issues like a FS of 300 was easily managed with a phone call and an extra
insulin order, UTI’s were treated on the spot prior to complications. I would
use single dose parenteral antibiotics, if warranted, as a first dose and then
continue PO Abx for example. Patients quickly learned that they had great care
at hand and ambulance calls disappeared. Second, the pharmacist delivered at
home and had direct access to my cell, the line was that no patient would run
out of meds. Any issues the pharmacist would call directly and fix it (from
patient needs a refill to insurance formularies changes). Also they would
deliver any acutely needed medication within the hour. We also had access to
next day laboratory work at home; a licensed lab tech would go to the home and
get whatever I needed and reports would be available that evening.
At first it was
involved due to barriers like patient, or family members did not trust us and
“tested” the system; after that barrier disappeared the problem became that I
could not find family members (they had stop worrying). Second, it takes
several visits to get people on the right track and a lot of education but with
time you end up seen them every 6 to 8 weeks.
One of the most
valuable aspects was to get into patients homes: you found chocolate stashes at
the uncontrolled DM patients, area rugs that were a hazard, mold at the home of
the frequently exacerbated asthmatic.
Another
important factor was setting goals; for me the plan was to keep the patient as
functionally as possible and minimize medications and medical visits. I was
astonished how for many of this patient medical care had become a full time
job. I strived to make sure that we were all on the same plan, from the patient
to the family member.
One story comes
as an example, I had this 92 year old, almost deaf, that had been in and out of
the hospital and nursing home due to “heart failure” after talking with her, and
her son, I promptly realized that eves so the quit 15 years prior she had smoked
for 60 something years, she never had been diagnosed as having COPD. I taught
my RN the difference between a COPD exacerbation and Heart Failure and we made a
plan. I surely next “heart failure” event was actually a COPD exacerbation and
was treated as such at home with great results. In short no more admissions,
after 4 to 6 weeks better oxygenation of her brain got her to converse and
remember things (she was diagnosed with dementia). The worse thing that
happened was that I never saw the son again; he stopped worrying about her
health.
To do this you
have to be willing to improvise and become a part time social worker, doctor,
home attendant, hospice worker and nurse. I created “ink” notes in my computer
and kept copies of all patients’ charts in the computer. Now with 3G I can just
access the office if I start this service again at my new office. You also need
a RN, or equivalent, that you can trust blindly.
One surprise
was how cheap and relatively easy it was to get it done. You also need to learn
to compromise, I don’t get x-rays just to prove heart failure. Third you have
to become humble and respectful (not easy for me) and learn to treat people on
their own turf.
I also found
out that because it was the same care team, issues could be solved with very
little talking as we all knew the patients and always did things the same way
(following our protocols).
One last big
problem became that patients expected a visit, I had to just drop by and say
hello or they would get “mad” with me when they found out I was in the
building.
José Battle MD NYC, NY
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