CASPER, Wyo. — When Pam Shellard wants to see her doctor, she takes a seat on her green couch.
From the comfort of her living room, she answers questions about her shaking arm and leg, about the hallucinations, about the swelling. As a fish swims lazily in the aquarium next to her, she complains about how one of the 19 pills she takes robs her of sleep. She wears slippers and leans back against a floral pillow as she remembers the hand injury that led to her surgery, which led to a brief brush with death, which led her here, to Parkinsonism and to Dr. Andy Dunn.
As she sits inside her central Casper apartment, she describes the time she fell and cracked four ribs. Masks and paintings of frogs peer down on her as she talks. Shellard swears she’ll never go back to a nursing home, that if she falls again, no one will know until they find her body.
“People cry all night and yell and scream and push the buttons and the bells go off for 45 minutes before everybody calms,” she says of nursing homes, the words spilling out of her mouth as if she can push the memory out with them. “People come in your room naked and sing ‘Amazing Grace’ to you, you’re shouting to get out of my room and they won’t leave and they’re kind of — it’s because they’re loopy.”
Fortunately for Shellard, Dunn has no interest in sending her to a nursing home. He doesn’t even want her to drive to his office. He works most of the time in the Mesa Primary Care clinic. But for an hour once a week, this apartment is his office, Pam’s green couch his desk. He has a stethoscope slung over his neck but kicks off his shoes. His medical assistant, Casey Garrison, wears scrubs but sits on the carpet with her legs folded beneath her.
Unlike most regimented doctor’s appointments, there isn’t really a time limit here. It’s not clear it would matter if there were one. Dunn, Shellard and Garrison mix questions about sleep (it sucks, Pam says) and Pam’s levitating foot (it isn’t really levitating, but it sure feels like it is) with talk of Dunn’s kids and Garrison’s nursing school plans.
“He’s my son and she’s my daughter,” Shellard says. “I’m so proud of both of them.”
“We come here for our therapy,” Dunn says, laughing.
It’s a mutually beneficial relationship. Because of her condition, Shellard doesn’t drive at night (which, she assures the room, is to the benefit of Casper). When it’s windy, she can’t get out of her car. Snow? Forget about it.
So Dunn — who oversees Wyoming Medical Center’s Sage and Mesa clinics — and Garrison come here, part of what Dunn says is maybe the only home-visit program in the state. It’s what he calls the Norman Rockefeller approach to medicine, referring to the artist’s painting of a doctor listening to the heartbeat of a little girl’s doll. He has a copy of that painting hanging in his exam room and in the waiting room at Mesa, he says.
It means spending more time with patients and less time in a sanitized room where patients march in, address one issue for 15 minutes and march out again. He visits patients who can’t come to the clinic. They know him and he knows them. He hugs Pam when he walks in and hugs her again before he leaves.
“We lost our way in medicine,” Dunn says later. “Too often doctors are made to practice in a manner that seems more like patient care is delivered on a conveyor belt.”
Working in a patient’s home lets the doctors take more time with patients and grow a connection beyond ticking off symptoms and doling out pills. Family can tune in. Questions are less likely to be forgotten. Everyone is more relaxed.
It also gives Dunn the chance to do more than what’s purely expected.
“We had a patient who was quadriplegic who lives at home,” Dunn explains. “Another immediate family member has terminal cancer and he’s not really seeing a provider, so as we’re there, he kind of pulled us aside and said, ‘Hey, I have pain everywhere, is this a good over-the-counter supplement to take for it?’
“That’s the kind of medicine we want to do.”
The home visits and the long conversations that come with them have another benefit: Office visits are expensive.
“Actually, Medicare’s already auditing our charts, how many visits,” Dunn explains. “So when we do this, we don’t want to report this to billing and all those other things because Medicaid — “
“You know what that means?” Shellard interjects. “It means every time he sees me, he’s doing it for free. He’s amazing.”
Dunn puts his hand up to ward off her praise and shakes his head at the ground. “It’s the right thing to do, though.”
Dunn says this isn’t an arrangement just for patients who can’t pay. It’s just that, if Shellard can’t physically get to the clinic every week and if Medicaid wouldn’t cover it even if she could, then what option does he have?
“The more that we come here, the more time we can spend,” he says. “Fifteen minutes, there’s no way I could understand what Pam’s going through. There’s just no way. And I’d be doing her a disservice trying to throw meds at her without trying to figure it out. There’s just no way. And that’s not safe, in my opinion.”
They’ve been visiting Pam’s apartment and green couch for the past six months, though she’s been their patient for years. Over time, they’ve wound through the restrictive corridors of Medicaid coverage: Sometimes to take the drug behind door number one, Pam has to try door number two first. Sometimes they have to dig for coupons. Sometimes they have to accept that one prescription is simply too expensive.
Garrison says their in-home visits started when they received a call one day from a sick patient who couldn’t get to the hospital.
Dunn “came to me and said, ‘Would you be willing to go do this visit real quick with me?'” Garrison says. “‘There’s a patient that’s sick and I don’t know if we’ll get there in time if we don’t go now.'”
Now Dunn and Garrison see a handful of patients in their homes. They hope it sparks a movement in home-based care. It could keep people out of long-term homes — which, Wyoming officials have said, are going to drive state Medicaid funding deeper into the red in the coming years.
A LOST ART
Doctors knocking on doors used to be standard practice. In 1930, “40 percent of patient encounters occurred in the patient’s home,” according to a study by the American Academy of Physicians. By 1950, it was 10 percent, and by 1980, roughly 1 percent of a doctor’s appointments happened in the patient’s house, apartment or green couch.
Dunn says there’s a focus nationally on seeing more patients and his approach — of taking time with patients, such as spending an hour in an apartment — is “very much going away from any type of national trend.”
“My hope is that quality will be more reimbursable than quantity,” he says.
But there are hints that this trend might be reversing. A Medicare experiment of in-home visits for the chronically ill saved the federal program $25 million in its first year, according to the Kaiser Health Network. Nine practices earned $12 million in bonuses.
In Wyoming, where the population is trending older and sicker, health officials have warned that the current Medicare deficit will explode through 2030. Tom Forslund, the director of the Wyoming Department of Health, has said the primary cause is the aging population and the cost of care in long-term facilities.
The cost of long-term care in Wyoming could balloon to $312 million a year by 2030, Forslund said. It’s currently $130 million.
Forslund has said that keeping patients in their homes longer will both save the state money while benefiting the patient. He told lawmakers in December that nursing home costs are 157 percent higher than home care costs.
Dunn says that nationally, a large chunk of Medicare spending goes to caring for the chronically ill in the last years of their life.
“The expense largely comes from hospitalizations,” he explains. “So whatever keeps patients out of the hospital (or out of expensive nursing homes) will save money — and home visits can help with this.”
On top of the financial side, he says, there’s the ability to make that patient-physician connection.
“I have brought Nerf guns to my patients in the hospital,” he says. “Because that to me is how medicine should be.”
He tells Shellard about how the Mesa clinic became an Olympic curling arena last week, when staff weighed down Kleenex boxes and pushed them along the floor. He jokingly admonishes her for bringing them bags of candy and cookies for Valentine’s Day.
The conversation continues winding from the serious (adjusting medications) to the more casual (Pam cleaned half of her closet). Shellard tells Dunn she’s been lifting one-pound weights — a big deal for a woman with two torn rotator cuffs and a torn bicep.
“Woah!” Dunn says. “Good! Keep moving. Love it.”
“I can’t pull my pants up hardly, it’s a pain,” she says. “If I can’t pull my pants up, I’m going to the nursing home.”
She reminds him that avoiding that place is her goal in life. She doesn’t want to go back to the nursing home. She wants to stay in her apartment, with its green couch and lamps and fish tanks. She wants to keep walking out the door, past the sticky notes reminding her to remember her wallet and emergency button, to keep going to the Humane Society to pet the dogs.
She’s not going back.
“No ma’am,” Dunn says.
Information from: Casper (Wyo.) Star-Tribune, http://www.trib.com