Roosevelt Island Doctor Jack Resnick On Keeping and Treating Patients At Home - Improves Quality Of Care, Saves Lives and Reduces Costs, Urges Support For Independence At Home Initiative

Image of Dr. Resnick From Independence at Home via Sevenload

Roosevelt Island's Doctor Jack Resnick has been a long time champion of treating patients at home. Doctor Resnick published this op-ed in the December 4 NY Times headlined "Bring Health Care Home" Here's a longer version of the article from Dr. Resnick:

Why Won’t Hospitals Let Doctors Fix Healthcare?
By JACK RESNICK, M.D.

I practice general internal medicine on Roosevelt Island, a unique community in the East River that had been, until 1971, Welfare Island. Many of my patients are homebound. They live in 50 apartments specially designed to accommodate people who had spent years as inpatients at Coler and Goldwater Hospitals, two chronic disease facilities on Roosevelt Island.

This homebound population has taught me what is wrong with the health care system.

Vinny was a 48 year old man who became a quadriplegic after being shot during a robbery in the hardware store he had owned and operated for many years. When he called me with high fevers, shaking chills and dropping blood pressure, I told him I was going to call an ambulance to take him to the hospital. He begged me not to do that. We argued back and forth, but he finally relented and I admitted him to the hospital. We successfully brought his urinary tract infection under control, and he survived the crisis. But he didn’t survive the hospitalization. There wasn’t sufficient staff in the hospital to turn him every two hours as was done routinely at home by aides. A bedsore developed, the wound got infected with a bacterium that breeds in hospitals and is resistant to almost all antibiotics. It killed him. Ever since then, I have struggled to keep my frail, elderly and disabled homebound patients out of the hospital.

It’s not easy. The healthcare system battles me every step of the way. The City’s ambulances insist on taking people to the nearest emergency room, not to the one where their own doctor is on staff. The State’s laws make it difficult to administer simple treatments in the home. Emergency rooms want to admit patients rather than send them home. Hospitals want to discharge people to nursing homes, not to the community.

Luba, 83, had emigrated from Russia in the early 1990s.Her arthritis kept her from moving around much, but she loved to talk about her career as a rocket scientist; working on weather rockets, not military ones. One day, a well-intentioned neighbor dropped by and, when she found Luba feverish and dehydrated from diarrhea, she called 911. After that, Luba disappeared. It took me two months to track Luba down to the nursing home to which the hospital had transferred her.

Luba, like many elderly people, became confused and disoriented when she got sick. This delirium, a condition that can improve when the underlying condition is removed, looks very much like dementia, a permanent change in a person’s brain. The staffs at the hospital and the nursing home had assumed that Luba was a demented old lady. They had sent her to live out her days in an institution, where her engagement with the world ended and her life would have been shorter. And she would have cost Medicare and Medicaid a great deal of money. Fortunately, when I arrived at the nursing home, Luba recognized me. I had to fight the bureaucracy for several months to get Luba home. But ultimately Luba’s personality and intelligence returned in full. It was crucial that I knew Luba and her mental status well, that I could differentiate hospital-imposed delerium from permament dementia. Being in familiar surroundings with well-known attendants, friends and family keep people well, sane, and happy.

Ruth was 93 when I became her doctor. Dementia had set in several years earlier and, like most people in their 90's, her blood sugar and blood pressure were a little high. A cardiologist had put her on three blood pressure medications, two drugs to lower her cholesterol and a daily aspirin. An endocrinologist was trying to control her blood sugar “tightly” with three diabetic pills. A neurologist prescribed two drugs for her dementia, a sleeping pill and two antidepressants. Each of these three assumed that her decrease in her energy and increasing fatigue could be ascribed to the problems they were treating. None of them spoke to any of the others. When I met Ruth, it seemed likely that much of her problem was overmedication. I cut her down to three drugs from her previous fifteen and, three weeks later, she was back in action.

The mantra of American healthcare is "more is better," more medications, more specialists, more tests. We have built enormous institutions -- hospitals, health systems, insurers, the drug industry -- and, like any institution, their primary mission is their own growth and survival. For forty years we have been asking these systems to rein in their growth before they choke the rest of the economy. They have given us health maintenance organizations, integrated delivery systems, case managers and, coming soon, accountable care organizations. None of these changes has or is likely to work. It's simply not in the nature of institutions to find ways to shrink.

Our healthcare institutions provide fine products and services. They work hard to convince us to use too many of them even when that’s not in our own best interests. We need to give the job of controlling health care to someone else.

In 2010 the American Academy of House Call Physicians successfully lobbied Congress to pass the Independence at Home Act (IAH).

IAH allows physicians to create organizations that will improve the care of the country’s sickest people - - the homebound, nursing-home eligible segment of the population -- while also decreasing its cost. It is scheduled for implementation January 1, 2012.

Independence at Home Organizations are founded on two underlying principles.

First, each patient must have a personal physician who knows him intimately and is available 24/7. Secondly, these people should be cared for in their homes -- not in offices, hospitals or nursing homes - - whenever possible. This change of the locus of care will dramatically decrease the infections, mistakes, deconditioning and delirium which are the inevitable attendants of institutional care.

Unlike other components of the Federal health care reform, the IAH approach has a long and dramatically successful track record. Hundreds of programs across the country have been providing care in the home to our frailest patients for decades. The largest of these programs is the Department of Veteran Affairs’ Home Based Primary Care Program. In existence for 30 years, the program serves tens of thousands of veterans spread over every state in the country.

The VA has cut hospital utilization by 54%, nursing home utilization by 82% and total health care cost by 24%. Comparable or better results are reported by most organizations using this approach, organizations that range in size from solo practitioners to small group practices to academic medical centers.

Technology is what makes it possible for individual or small groups of physicians to provide complex care at home.

The Obama Administration has aggressively promoted electronic medical records. A physician with an IPad has more information available about a given patient than any institution. That IPad’s internet access also allows him to rapidly search for the best answer to any urgent question - much more rapidly than awaiting the arrival of a hospital-based consultant.

With just a few drops of blood, a physician at the bedside can now get crucial test results in seconds. Waiting hours for staff to draw the blood, transport it to the lab, perform the test and report the results are things of the past.

Similarly, portable X-ray and ultrasound equipment are wheeled into a patient’s home in suitcase- sized containers. Images are fed digitally hundreds or thousands of miles away where a report is generated and returned in minutes -- not in hours or days. Even CT scanners can be rolled up to the patient’s front door. Sophisticated remote monitors measure every imaginable parameter of a patient’s status and notify the physician remotely. Audio visual equipment can even allow nursing personnel to watch over many people dispersed over a neighborhood. Consultants are already seeing many complicated patients from a distance over webcams. And their consultations are much more productive when conducted in the virtual presence of the patient’s personal physician.

The role of hospitals will change. Acutely ill patients will still be brought to an emergency department for evaluation and stabilization. Those people who need an operating room or an intensive care unit will be hospitalized. Anyone else will be returned home to the care of a personal physician and a dedicated nursing staff who know them intimately and who have at their disposal technology’s tools.

Physicians who make themselves available 24/7 to these complicated patients will be well compensated. Doctors in IAH organizations, who provide measurable high quality care and save Medicare money, will share in those savings, and those savings should be considerable. Conservative calculations suggest that these doctors will earn as much as today’s most highly paid specialists. This will quickly change the calculus of health care economics and end the shortage of primary care physicians.

IAH has the potential to do wonders for the national economy. Cutting Medicare’s cost dramatically will make the work of the Congressional budget supercommittee much simpler. And moving much of health care into the home will create hundreds of thousands of new jobs across the country.

Applications to form IAH Organizations have not been issued. Medicare has, instead, been focusing on other portions of the Obama Healthcare Reform that will encourage and reward hospitals and other large institutions for once again rearranging the deck chairs on their sinking ships. Through IAH, doctors have the means to address and solve the healthcare crisis.

Let us move healthcare into the home where it is safer, cheaper and more effective.

(The writer is a general internist in solo practice on Roosevelt Island. He spends half of his time making house calls to 50 homebound patients. He has been working for several years with the American Academy of House Call Physicians on getting the Independence at Home Act enacted and implemented. You can meet some of his homebound patients in a 15-minute video on therooseveltdoctor.com.)

More information on Independence at Home Organizations available here.

Learn more about Doctor Resnick and some of his Roosevelt Island patients from this video.


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