About four years ago, staffers at the day care center that Magerine Cowans attended "wanted to direct us to a hospice," Cowans's daughter Jan Hall said. And no wonder: Cowans "was just totally zonked out," Hall said.
Today, Cowans, 85, has Alzheimer's disease, hypertension and arthritis in one knee, but she's no candidate for hospice care. She still lives at home with her three daughters -- Hall, Toni Cowans and Sandra Cowans -- and Hall says a house call program operating out of the Washington Hospital Center deserves much of the credit for her longevity.
"We don't have to worry about getting her up and out of here for doctors' appointments," said Hall. "We don't have the worry of . . . will she be feeling okay and ready to go to the appointment? We don't have to worry about getting the medical transportation that we had to get, which was very expensive and time-consuming."
The Cowans situation is typical, in that most older people rely heavily on family members as their health problems grow. "Even if they need help caring for themselves," said a report issued by AARP in 2003, "older Americans prefer receiving services that allow them to stay in their current home." With nursing home care in the United States costing more than $100 billion annually -- almost half of it coming from the federal/state Medicaid program -- policymakers continue to seek new ways to help people avoid institutional care.
Physicians Eric DeJonge and George Taler started their house call program in 1999. "The goal was to create a team, a health care team, that brings comprehensive care to frail elders in their homes, because it's hard for them to get to the doctor's office, and they end up experiencing a lot of expensive 911 calls, ER visits and hospital stays that we thought were probably unnecessary," said DeJonge.
DeJonge said the program has about 500 people under active care, each served by a staff of seven that includes geriatricians, nurse practitioners and a social worker.
By visiting only homes in eight District Zip codes located east of Rock Creek Park and by carrying little of the overhead of office-based practices, DeJonge said, his program is proving financially viable: The average house call generates about $100 from Medicare, and Medicaid provides about $1,800 per patient per year for social work services. Donations from foundations and individuals typically total about $250,000 annually.
DeJonge said his patients are pleased "that they can get the care when they need it -- in the home, where they prefer to receive it. The social combined with the medical . . . if you bring both to the home, then people and families can make it."
Hall said her mother's previous doctors didn't communicate with one another. As a result, she said, they burdened Cowans with unnecessary drugs and hospitalized her repeatedly before implanting a heart pacemaker that she didn't need. With the Washington Hospital Center program, "you've got one doctor who sort of directs everything," Hall said.
"This gives us so much peace of mind," she said. Without the program, "we wouldn't be able to handle it as well as we handle it now. . . . This will certainly allow her to stay out of a nursing home."
Needle in a Haystack
"Finding a senior who wants to go to a nursing home is little like searching for a needle in a haystack," said Tricia Neuman, director of the Medicare Policy Project at the Kaiser Family Foundation. "I think you'd be hard-pressed to find a senior who truly wants to enter and live in a nursing home. It's often a last resort."
Starting this fall, Medicare beneficiaries in selected communities will be invited to enroll in a half-dozen demonstration projects as the federal program seeks new ways to control spending while improving care. For example:
* Two thousand people living at home in Oregon and Washington will each receive a "Health Buddy" computer that can transmit blood pressure and other readings to clinicians who can then ask the patient, via questions that pop up on the monitor, what might be amiss. (The patient replies by pushing one of four buttons on the screen.) The medical staff can then decide whether the patient needs to be seen.
* In New York, similar devices and additional on-site services will be provided to up to 7,000 residents of "naturally occurring retirement communities," or NORCs -- housing complexes where most residents are older than 60.
* In Texas, California and Florida, 15,000 Medicare patients will be able to receive round-the-clock home visits from physicians. The goal is to improve care while reducing expensive emergency room visits and hospital admissions.
The Department of Veterans Affairs also operates a home care program that serves 11,000 people with multiple health problems. In a statement at a Capitol Hill meeting of the White House Conference on Aging last month, Thomas Edes credited the program with "a 62 percent reduction in hospital days and a substantial reduction in emergency room visits and nursing home days."
Edes, a physician who oversees the program, said that although it costs nearly $10,000 per person per year, "this comprehensive home care to this very sick population was associated with a net 24 percent reduction in total cost of care."
A team of nurse practitioners, social workers, rehabilitation therapists and dietitians visit homebound patients and their caregivers to deliver medical care along with information about meals, exercise, medications and community resources. A major goal is to help keep patients at home as long as possible; the program also includes palliative care for those nearing death.
"I believe this model of care should be available for all Americans as they live with serious illness in old age," Edes said.
One similar program is available -- if not for all Americans, at least for those who are sick enough by Medicaid's standards to qualify for nursing home care, who live in certain states and who have a nearby medical institution with deep financial pockets and the willingness to try something new. It's called PACE, the Program of All-inclusive Care for the Elderly.
Eleven thousand people in 18 states are enrolled in PACE programs, which combine Medicare and Medicaid funding -- about $4,800 per person per year, on average. The sponsoring organization, which receives those funds, is responsible for delivering a comprehensive package of medical care and social services -- ordinarily at a day care center, sometimes at the person's home, and even at a hospital or nursing home if the participant needs to be admitted. According to the National PACE Association, the average age of people joining the program is 80 and half of new enrollees have at least some dementia.
Virginia and the District have no such programs. Maryland's sole PACE location is in Baltimore, where dozens of elderly people are brought daily to a center where they receive medical care, occupational therapy, social services, meals and other assistance from Hopkins ElderPlus, sponsored by the Johns Hopkins Medical Institutions.
Karen Armacost, the program's director, said it's not difficult to fill the 150 slots in the program, even though two or three participants die in a typical month.
Satisfaction is high among participants and their caregivers, who find it "wonderful to be able to have this one place to go to for answers and guidance. . . . A lot of people refer to it as one-stop shopping. . . . The thing that they most appreciate is the comprehensiveness and the coordination of the care," Armacost said.
"Once a person enrolls, we provide all the care that they need for the rest of their life," said Robert Greenwood, a vice president of the PACE association. "If they need to go to the hospital, we pay for the hospital care; if they need to go to a nursing home, we pay for the nursing home care. So the reason this model works is because the program . . . will invest money in keeping people out of hospitals and out of nursing homes, because that's where we lose money. It's such a nice model because it really aligns the financial incentives with the clinical incentives and with what people want."
Why aren't there more PACE programs? Among the factors, according to Greenwood, is that some states prefer to spend their Medicaid dollars on other projects. In addition, "there are major start-up costs," Armacost said, "and a lot of health systems and organizations just don't have those kinds of start-up funds." Just as the Washington Hospital Center helped get the house call program underway, Hopkins provided the Baltimore PACE program with seed money. Armacost said the cost of creating a program and subsidizing it while the first participants are enrolled can be as high as $2.5 million.
As for what that investment produces, the value of the PACE program can be measured in different ways.
"When we poll our participants and caregivers, 100 percent say they would recommend the program to a family member or friend," said Armacost. On the other hand, Greenwood said, "the cost-benefit analysis is a little bit more difficult": a thorough study of the financial impact of PACE won't be done for a few years.