Case Study

Jim (not his real name) was a 71 year old Korean War veteran and retired construction worker. He had not seen a physician since in military discharge in the 1950s. In 2006, he enrolled in a managed health care program for dual eligibles, when all such individuals were passively assigned to a program as part of implementation of Medicare Part D. A nurse from the care network to which he was assigned saw him several times at home. He had been homefast for over a year. He lived with a friend for the past 40 years, who served as his primary caregiver. He had several half-siblings and nieces in town.

Due to pain and general disability and refusal to leave his apartment, I was contacted by the RN care coordinator to provide a medical house call. The patient was assigned to the clinic, an FQHC, affiliated with the University where I work and lived about 1/2 mile from the clinic. Obviously, he had never been to the clinic, which had no record of his existence. I went to see him that afternoon. He was reclining on the couch and complained of rib pain for the past year. He had orthostatic symptoms when standing and was breathing at 40 per minute. A home CXR revealed a infiltrate and effusion obscuring the entire left lung. Home care was initiated. Oxygen saturation was 90%. Opioids for pain were started. A second visit two days later revealed improved comfort. Home hospice was requested. He accepted a sponge bath, the first in weeks. His pain increased over the next day. Increased opioids were prescribed. A hospital bed was delivered. About 1/2 hour after getting into the bed, he was found by his roommate to be dead. This was less than 1 week since he was first seen by a doctor.

How many others are there like Jim - homebound for medical or psychiatric reasons and lacking medical care? There are estimates that as many as 10% of the population is limited in their ability to leave home. The health care system has almost unlimited resources to provide hospital care, but home medical care is rare or non-existent in many communities. This blog will chronicle the efforts to correct this situation and get care to people like Jim, particluarly in Minnesota.