BALTIMORE -- Mary Kuhar, a 74-year-old widow, suffers from a host of life-threatening ailments. Emphysema is strangling her lungs; in order to breathe, she must be hooked up to a portable oxygen tank. Bruises encircle her right eye, evidence of a recent fall in a bathtub that landed her in the hospital and may have been caused by her rheumatoid arthritis. She suffers from a heart problem that requires her to take medication several times a day.
As debilitated as she is, the fact that Kuhar is able to live on her own is largely due to an innovative program based on an old-fashioned notion: her doctor makes house calls.
Every six weeks, and more often if necessary, a physician and a social worker from the Francis Scott Key Medical Center visit Kuhar, one of 200 elderly patients enrolled in the Elder House Call program. The team of geriatrics specialists makes 1,000 house calls annually, spending as much as 90 minutes talking with and examining patients like Kuhar to make sure they are eating regularly, taking medication and functioning well enough to stay out of a nursing home.
The program was founded a dozen years ago by John R. Burton, the clinical director of the geriatrics division at Johns Hopkins Medical Institutions, of which Key medical center is a part. Burton says he regards the program, similar to one at St. Vincent's Hospital in New York City, as a more humane and possibly less costly afternative to unnecessary hospitalization or placement in a nursing home.
"By making house calls," Burton said, "you get a sense of medicine outside the institutional walls" and are able to see how well a patient functions in his or her own home, rather than in the restricted and often harried environment of a busy clinic or emergency room.
Like Kuhar, some patients are visited every six weeks. Others, who are healthier, receive a house call every six months.
"It's people versus patients," said Kris Kuhn, a doctor specializing in geriatric medicine who is performing a three-month rotation with the program. "To see elderly people in their homes is another dimension in understanding what their lives are about."
Half of the program's participants are widowed; their average age is 77 and most are women. Several people in their twenties, the victims of head injuries, are also enrolled. The main eligibility requirements for the program, which has a waiting list, are the ability and desire to live independently and the inability to come to a doctor's office for routine checkups. "It seemed crazy to have them take an ambulance to the clinic," Burton said.
According to Burton, one woman was transported by ambulance to the hospital emergency room more than 200 times in one year, the result of medication problems and emotional difficulties. After she joined the program and doctors regularly made house calls, the frequency of her trips was cut to one per month.
The Elder House Call program has its share of both successes and failures. A quarter of the patients visited during a year die, and seven percent will be transferred to a nursing home after the team determines they can no longer live independently. A few improve while in the program, some enough to begin coming to Key's ambulatory clinic for their appointments.
Thomas E. Finucane, the physician who directs Elder House Call, said he envisions home care as playing an increasingly larger role in treating geriatric patients. "As technology becomes more portable," he said, "we'll take the hospital to the home."
Finucane said he thinks the program, which has a budget of about $100,000, eventually will be self-sustaining. Currently, 80 percent of the cost of the house calls -- about $72,000 -- is reimbursed by Medicare, the state-federal government program for the elderly.
Kuhar, at her most animated when discussing her favorite television shows, which include "I Love Lucy" reruns, said she thinks the Elder House Call program is good for her because it has enabled her to live relatively independently, albeit with considerable help from a network of services. "I do not want to go into a nursing home," she said emphatically.
One recent morning, Kuhn gave her a physical examination, paying particular attention to the injuries she sustained in a fall in the bathtub. Social worker Frances Lodder asked her about recent visitors and about her daily activities, which include twice-daily visits from a home health aide who helps her bathe, and regular calls by her daughter who lives next door. Kuhar also is served by Meals on Wheels, which provides her with a hot lunch and leaves her a sandwich for supper.
Later that day, Burton, accompanied by two undergraduates who are spending the summer working with the program, made a call at the home of 88-year-old Jennie Brown.
Brown has been enrolled in the program for three years, a circumstance that has enabled her to stay in her home of 65 years. Although she is severely disabled by osteoarthritis and muscle degeneration and suffers from recurrent urinary tract infections and hearing and vision problems, she can still cook her own meals. She has been widowed for 24 years but her pet collie Trixie helps her cope with loneliness, as do periodic visits from a sister and from friends.
Brown's desire to stay out of a nursing home is fierce. Although her home has been burglarized, she says she is not afraid to live alone. She says she likes the Elder House Call program, but protests, "I feel like I'm too much trouble" for everyone. But she clearly relishes the attention from the team and tells Burton, whom she regards with obvious affection, that she wishes she had something to offer him to eat.
Like Kuhar, Brown is connected to Key medical center by a call box connected to an emergency dispatch service. If she does not reset the box twice a day, an operator will check on her.
At Burton's request, Brown, her fingers trembling from muscle degeneration, spends about 10 minutes trying to change the battery in her hearing aid. After several attempts, she is unable to do so, something the team notes.
"If you want a good sense of what a patient can or cannot do, you have to see them in their home," said Burton.
Sometimes the program has unexpected dividends. LaVeda DeVone a Dartmouth College pre-medical student who grew up in Baltimore, began working as a summer intern with Elder House Call in June. She said she was so impressed with the program that she got her own grandmother to enroll. "Home care lets people feel comfortable," she said. "It's a learning experience for everyone."