Just How Dysfunctional Is Frail Elder Care in the U.S.?

Tuesday, May 19, 2015

Older Adult and Their DoctorVery, very dysfunctional. You need evidence? Try these two tales.

First, a remarkably illuminating piece of research was released on March 2 concerning the Meals on Wheels program. The title was “More than a Meal,” and it showed that people who got warm meals home delivered by volunteers 5 days per week did better in many ways than people who got frozen food delivered once a week and much better than those who were on a wait list for Meals on Wheels. That finding was not surprising: Our mothers could and did tell us enough to expect that finding, though it is good to have it properly documented.

What is so profoundly dysfunctional is that there were eight U.S. cities participating that each had waiting lists for Meals on Wheels of more than 6 months. That’s right: The program to provide food so that elderly people could stay at home, live with dignity, and count on a friendly face coming by on most days has a waiting list longer than many needy people’s life spans. What happens when cities build up 6-month waits for food? Most on the waiting list can’t shop; most can’t cook. Some neighbors help out. Some find enough money to get fast food. Many get sick or dizzy and end up in the emergency room, the hospital, and then a nursing home. All are hungry, and none thrive.

The cost of home-delivered meals for a year is less than just the ambulance trip to the emergency room. The cost of one hospitalization would pay for a hundred people for a month. Yet we are primed to provide the ambulance and the hospital but not lunch! The funding for Older Americans Act services has increased less than 5% in a decade, while the funding going to Medicare has doubled. These priorities were not set by 88-year-old women living alone in poverty but by much younger men scared of heart attacks and wanting assurance of rescue.

But wait; there’s another story. This one is about my mother, now in her 94th year. She caught a cold, which progressed to pneumonia, and she was quickly in a precarious state. The craziness started when her primary care physician, making a home visit (yes, a home visit!) noted that my mother could not get a good broad-spectrum antibiotic except by going to the emergency room, because all pharmacies near her small-county seat in western Pennsylvania were closed on Saturday night and all day Sunday. Feeling like a participant in a modern-day Iditarod, I got the antibiotic and drove 4 hours to deliver it, and it actually did the trick. My mother turned the corner within 12 hours and was breathing much easier by Sunday afternoon.

But then she was very weak and severely dehydrated, which causes nausea, and therefore she required some way to accomplish hydration other than just by drinking fluids. I asked about home health care getting her some intravenous fluids. The answer: That would take 48 hours to set up. I asked whether I could buy or slip away with the fluids and an IV setup; after all, I’m a physician. That would break too many rules. I stumbled onward, asking what would happen if my mother were in hospice. Miracle delivered! In hospice, she could have an IV at home that day! Her primary care physician agreed that without something changing, her prognosis fit the hospice requirements, and having an IV could hardly count as “curative” medicine—except, of course, that it did put her back into her usual state of health, and then she left hospice care.

Now let’s think about this. The usual course would have been an ambulance to the hospital, an emergency room visit, and a hospitalization, perhaps followed by a few days of skilled nursing facility care “to get her back on her feet.” And that course assumes no serious complications like a fall or an infection. Hospice cost about 1/10 as much. But why did her doctor and I have to figure out an end run around the rules that seemed to connive to ensure that she would have to go to the hospital, if not to get the antibiotic, then to get the fluids?

This time, the priorities were set by service providers seeking their convenience and perhaps their incomes, not by 93-year-old women very much wanting to live out their lives at home.

Most of us will be relatively healthy for most of our lives. We will end up spending about half our lifetime health care costs in the last years of life, when we are frail; needing food delivered by a friendly volunteer; needing that antibiotic to be available without going to the hospital; and needing some IV fluids at home today, not after a lot of paperwork gets done. We’ll need that remarkable primary care doctor who visits at home. But I sure hope that not everyone needs a physician daughter who can find one more question to ask to evade the ruthlessness of a seriously dysfunctional system, and we must all insist that no elderly person will ever need to wait 6 months without being able to count on food—not now, not ever, not in the United States.

If you agree, talk with your Congressional representatives today about reauthorizing the Older Americans Act and call on them to actually increase the funding to account for the increasing numbers and the current shortfalls. Tell them to take Older Americans Act funding out of the pool that is at risk of sequestration. Join us in pushing for some leadership communities to focus on building a care system constructed around the hopes and fears of frail elderly people themselves. Join the campaign by writing to us at info@medicaring.org.

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