Next Generation is a Brigham Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email firstname.lastname@example.org. This month’s column is written by Anita Rao, MD, a second-year Primary Care resident in the Division of General Internal Medicine. Late last year, Rao completed a two-week elective with the Home Hospital program, which provides hospital-level care to eligible acutely ill adults in the comfort of their home. For more details about the program, read a previous CRN story here. Please note that some patient details may have been altered to protect patient privacy and confidentiality.
Nestled in a rustic community, Rose’s home was like any other modest dwelling. As I walked in with my colleagues, a nurse and a hospitalist, I could see her kitchen, dining table, bathroom, bedroom, living room with a sofa, some mismatched chairs and an old TV set. Lying atop her dining room table were stacks of papers, magazines and books. Tucked in between a few piles of papers were several pill bottles filled with Rose’s medications. She had a scale next to the TV and a portable oxygen tank adjacent to it.
Over the last six months, Rose had grown increasingly short of breath, but refused to go to the hospital because she didn’t think she was sick. Moreover, she didn’t have her own car and tried not to ask others for favors. “’I’m fine’” she would say to her family. She rarely complained, her daughter, who was visiting at the time, told us. Finally, after much convincing, Rose agreed to see a physician in the Brigham’s Emergency Department, but only if she could go home afterwards. During her appointment, Rose was found to have a low oxygen level and other signs suggesting a heart failure exacerbation — when the heart muscle does not pump blood as well as it should, causing fluid to back up into the lungs and other parts of the body. She would need to be admitted for further care. But in Rose’s case, she wasn’t being admitted to a room inside the hospital. Instead, she could go home and be enrolled as a patient through the Brigham’s Home Hospital program. I was standing in her living room as her doctor.
The Luxury of Time
Rose was one of several patients I met in their homes during my two-week elective with Home Hospital. This program, led by David Levine, MD, MPH, MA, a physician and researcher in the Division of General Internal Medicine and Primary Care, provides acute medical care to each patient within the comfort of his or her own home.
As a primary care resident, I was drawn to the Home Hospital program because it seemed like a hybrid between inpatient and ambulatory (outpatient) medicine. Patients can receive acute-level care with providers that have the practice style of a primary care physician. Patients did not need lab testing done multiple times per day, vitals checked every four hours or a slew of consultants. Instead, most patients only had labs done once each day and vitals were checked twice a day. Consults were rarely called unless it was necessary. In addition, compared to the traditional inpatient setting where one team is often caring for 20 patients at a time, the Home Hospital program is set up so that physicians are caring for no more than four patients a day. This provides the luxury of time — time to truly understand the social context in which a patient spends most of their days. Caring for patients inside the home helps care teams understand the reasons behind why a patient continues to be readmitted to the hospital for issues such as pneumonia, exacerbations of heart failure, asthma, chronic obstructive pulmonary disease and cellulitis. Caring for patients in their home gives health care professionals the ability to provide patients with truly individualized care.
During my time with Rose, I had the opportunity to walk through her kitchen and show her which foods to avoid eating for health-related reasons, perform a home-safety assessment and help her calibrate her home oxygen probe. I could show her, using cups in her own cabinet, how to restrict the total amount of liquids she drank each day to avoid fluids backing up into her lungs. In addition to learning more about Rose’s home, we sat down with her and learned more about Rose as a person. She told us about her role on the board of the community’s home association, a responsibility she enjoyed very much, her childhood memories and stories about her grandchildren.
Throughout my rotation with Home Hospital, I couldn’t help but wonder — wasn’t this how medicine was practiced in the past? Doctors used to make house calls regularly. At some point in history, medicine stopped taking place in the home and started to become more centralized in a hospital setting. While there are many benefits to providing and receiving routine care in a hospital, I often wonder whether this has caused many of us to lose touch with patients and forget the context in which a patient lives before entering the hospital environment. All too frequently, we become reliant on assumptions or implicit biases to fill in the gaps or suggest a treatment plan that is unrealistic for the patient to follow outside the hospital.
I think all patients with medical conditions appropriate for care in the home setting should receive the type of care Rose received through the Home Hospital program. My interactions with Rose were so special because I had the opportunity to provide truly personalized care to her and learn more about who she was as a person, not only as a patient. As legendary physician Sir William Osler once said: “The good physician treats the disease; the great physician treats the patient who has the disease.” The next time I meet another patient with heart failure in the hospital, I’ll think of Rose.