Posts Tagged ‘nursing home’

As I do every Friday, I was rounding at one of our local nursing homes after precepting the night before at the DeSales Free Clinic. Friday mornings like these are always particularly challenging for me as I am often struck not by the differences but by the similarities between the ‘underserved’ unsheltered/sheltered homeless and the ‘underserved’ elderly living out their days in a nursing home. Nursing homes are not all doom and gloom and depressed mental pictures of our loved ones wilting away just as caring for the homeless is not a fruitless effort bound for failure. There is actually a great deal of love taking place in both settings. Don’t believe me? On Friday, a long time patient in the nursing home suddenly took a turn for the worse. I frantically wrote orders for medications that I though would ease her transition out of this world. One hour and fifteen minutes later, my lovely patient left this world to another. She left so quickly that her family was not able to make it to her bedside in time. Instead, she was loved out of this world by a nurses aide and an activites assistant to the hymns of her childhood and recitations of her favorite passages from the Good Book. So often, we in medicine think that our only measure of success is cure. I solomnly object.

Last year, I saw a patient in the Free Clinic with one of my students. The student had done a great job seeing the patient, coming up with a reasonable plan and conveying it to me. The patient essentially had a terrible cold. No need for antibiotics or anything more than some OTC medications that we could provide. From my seat in the presentation area, I could see the patient out of the corner of my eye. He looked terrible. Not the “call an ambulance” terrible, but a weary-feverish-please-just-let-me-rest terrible. As we went into see the patient together, we realized he was in the emergency shelter which clears out no later than 8am. This man would wander the streets and try to find somewhere to rest until the shleter opened back up. Your daily goal of survival is rarely replaced with rest and recooperate. It turned out, this man had a car (eureka!). He also had a brother 1 hour north who was going to be away for the next week and had offered my patient the couch while he was away. The problem? The patient’s car needed antifreeze and he had no money.

As we returned to the waiting room, I asked my student to share a memory about being sick and the things that helped him feel better. Then i asked him to remeber how sick he felt and picture not eating or drinking and then walking around or sitting in 20 degree weather while the wind slaps your face as if to remind you of your worthlessness. Before we learned the patients social situation, we of course knew that we couldnt cure his cold. Most viruses are just a test of our patience since more of the things we give for comfort only work marginally well at best. But we were nonetheless ready to arm him with Mucinex, Robitussin, Motrin and anything else we thought would help. In reality, what he needed more, was rest. And the best way to get him rest, was to get him antifreeze. On the way home from clinic that night, I bought him two large containers of antifreeze and dropped them back off the next morning where a very greatful patient awaited and at last would get a good nights sleep.

In street medicine, as with the nursing homes, we cannot simply cure the root cause that landed our patients in ther current surroundings. It is the complex fabric of their lives and health that have to be carefully understood before real comfort -and perhaps cure – can be achieved. This can be a real challenge to newcomers to these areas of medicine. There is a potential for new providers to become frustrated and overwhelmed and run for the hills while wildly flapping their arms screaming about the unfairness of it all. What we find in street medicine is that often the cure comes from the comfort. The brokenness cannot be cured with pills. It can only be cured with comfort. Comfort doesnt’t take money, doesn’t take insurance (thank God) and doesn’t take a master’s degree. It actually takes something much more valuable. It takes tenacity mixed with vulnerability to go there with your patient. To a place that is raw and uncomfortable and can chalkenge you in ways you never thought possible. To a place where we celebrate the small victories and push on when set backs occur. In many ways, this is what our patients need more than anything else. Belief that they are actually worthy of something better than this.

“Sometimes it’s easy to walk by because we know we can’t change someone’s whole life in a single afternoon. But what we fail to realize is that simple kindness can go a long way toward encouraging someone who is stuck in a desolate place.” – Mike Yankoski

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I have been working weekly at several nursing homes in our area for the last few years. I could spend an entire posting talking about how I think our elderly nursing home population ought to fall in the ‘underserved’ category but I will spare you that soap box for today.   I am extremely grateful to have bosses who understand my predilection for the homeless population and for leaving no stone unturned when I’m interviewing patients. It never ceases to amaze me that was the right series of questions you can uncover a world of hurt that the patients been through. When we close our eyes and picture a typical nursing home patient we are stuck with an image of grandma- with her tight rows of freshly curled hair resulting in the beloved (and highly flammable) grandma-helmet-hair. Or maybe a shuffling old man proudly sporting his WWII VFW hat with pins from his uniform.

You are far less likely picturing someone whose reflection resembles yours.

Many of my younger patients have lived in our nursing home system for quite a long time for one reason and one reason only. No one realized they were homeless at any point during the hospital stay or early on in the nursing home stay. Once they started to complete the rehab goals, the social services team comes to the realization that there is no discharge plan. I sometimes referred to this phenomena is the “fog of war- medicine style”.   After 9/11, George W. Bush made many decisions that he later reflected upon in his book “Decision Points”. He realized that perhaps they were not ultimately the best decisions, however, he felt he had done the best he could with the information available and the time allotted to make the decision. He cited the fog of war it during the decision-making process. This is common throughout history and no one really (successfully) faults people for it.

This phenomena also happens in medicine.

It goes like this: Patients are banged up, super sick or maybe have had a decompensation an otherwise chronic stable medical condition which leads to the hospitalization. In the world of hospital medicine, length of stay in the hospital is looked at very closely. In the haste of making a reasonable discharge plan there’s often a lot of questions that frankly just aren’t asked for a variety of reasons. Case managers and medical teams have a difficult job and are often asked to do the impossible. But sometimes, I think we don’t dig deeper into the answers our patients give us about their living situation. For example, patients often say they are going to live with their friend after discharge. At face value, this sounds great. Discharge plan complete. Until you ask if they have talked to their friend about this plan. Often, the answer is no. Or, another common scenario- a patient says they were living with a brother, sister, friend etc. prior to coming to the hospital. Somehow, this is translated by the discharge team that the patient will be discharged back to their prior living situation. No one asks, and the patient doesn’t mention that they can’t or don’t know if they can return. The patient is discharged from the acute care setting (hospital) to their short-term rehab facility and everything seems great until a simple question like “Hey, where you going next?” is asked. The response – a blank look from the patient and then silence sets in.

In the time that Brett and I have been in the nursing home system, we’ve noticed a large variety of patients whose social situations and living situations perhaps were tenuous at best prior to hospitalization. Homeless or not, many people’s social support is based on superficial interaction. Hanging out, watching TV, playing card, shooting the bull (not to be confused with cow-tipping. I am from Indiana after all). In the face of acute illness, that social ‘support’ is tested and often disappears when these patients need the most. The couch is suddenly unavailable. The car has been repossessed because of missed payments. The housing has dried up. Perhaps your truck driver who is now an insulin-dependent diabetic or perhaps had seizures and is no longer allowed to drive the truck. Not only does this person suffer from a loss of employment but many truckers sleep in the cab of their truck. They don’t have permanent housing because they live a life on the road.

A few weeks ago, Brett and I asked case managers from three different nursing homes in three different parts of the Lehigh Valley how many patients they thought were homeless in their facility. Without consulting a census or really doing anything scientific, they came up with 22. That’s 22 patients who have absolutely no where to go if they were to be discharged right now. This is astonishing. What complicates the situation further is that case managers who work in skilled rehab facilities don’t have the training to find housing for patients who are homeless. This isn’t a typical part of any case management training and is purely learned on the job or because of personal interest. And therefore the patients who are easier to move out of the nursing home seem to move out of the nursing home. The homeless patients tend to sit … hang out… and stay. There’s nowhere for them to go and no resources by which to move them.

The Point In Time (PIT) is a physical head count of the homeless on one given night that is universally chosen. Over 3000 cities participate in performing the PIT on this date in an effort to count the homeless and attempt to extrapolate trends about homelessness in your area and nationally. The data is reported to the U.S. Department of Housing and Urban Development (HUD). While HUD says it “does not directly determine the level of a community’s grant funding” (hud.gov), it is required information to report when applying for HUD funding. It would be hard to imagine that those numbers are not somehow taken into account when determining distribution of funding. It is not a perfect sampling tool by any means (a different soap box for a different posting) but it is concerning that these ‘nursing home patients’ are unaccounted for. These are patients that if they were not in a nursing home would be in one of our shelters, on the street or perhaps (if lucky) squeezing out another couch to sleep on. In essence, they should be recognized and counted.

In the last post, I talked about recognition of existence in the context of being a fledgling street medicine program. This same concept applies here too. In order to properly allocate care to the homeless, we must first know where they are. To know where they are, you have to know where to look. The homeless are all around us, hidden in plain sight, waiting to be recognized.