The first time I heard the phrase patient-centered
medical home, I took it literally to mean that there was a new concept of patient care that had the locus of care at someone's actual house. It made perfect sense to me and, quite frankly, I was puzzled as to why it had taken so long for this concept to be put forth. However, I soon learned that a patient-centered medical home (PCMH), despite what it sounded like, was not a literal "home" but rather described how a clinical practice can function as the central hub of patient information, primary care, and care coordination for a defined group of patients.1 The concept had a collaborative team effort as its foundation with the overarching goal to improve the delivery of health care.
I firmly believe that one's home, in one's own bed is the preferred place to receive care when one is sick. Trying to ensure that one receives care at home if at all possible can be an especially precarious adventure as one gets older and faces a myriad of very difficult questions. Will I be able to stay in my own home? Who will help me when I no longer am able to take care of myself? How will I receive medical care, and who will provide it? How much will it cost to stay at home? Is it less expensive to be cared for at home than in a nursing home? Will my insurance cover it? Where do I start? Who do I call?
Whether you are considering taking care of an aging relative or in the process of becoming an aging relative yourself, I hope you can benefit from hearing about my experience with taking care of my elderly parents, whose most ardent wish was realized when they both died peacefully at home, within several months of each other. Here's some of what I learned along the way.
Growing older and frailer means you have less power over just about everything—joints, hearing, appetite, bladder, home health aides, and family members. The impact of the loss of control and independence cannot be overestimated, nor are the changes that go along with that loss always graciously accepted.
Having to give up the car keys is huge! Yet the fact remains that it is just as dangerous driving less than a mile to get the daily paper as it is going to a doctor's appointment two towns over.
The involvement of your local visiting nurse association is crucial, especially since the agency will work hard to provide reimbursable services. The VNA is also an invaluable repository of a list of community resources and how to access them. Although a home care nurse oversees each case, the VNA is able to provide only a portion of the actual hands-on care, such as a home health aide three times a week to provide a bath. If more care or closer supervision is necessary than can be given by a daily visit from a family member or home care provider, fasten your seatbelt because the cost of private in-home care becomes downright eye-popping, especially if around-the-clock care is required.
Long-term care insurance might not be the answer to your financial prayers because each policy differs in how it defines who qualifies for care and what circumstances will be covered. In addition, coverage might still only represent a portion of the actual costs. Be sure to read both the bold and the fine print.
Identify an uncomplaining family member or friend to be responsible for all the (redundant) paperwork and (redundant) telephone calls that accompany home care. I periodically had to lay my forehead on my desk during some of the interminable telephone "on-hold" times and take slow, deep cleansing breaths.
Relationships within families never really change; they just get incredibly magnified and more complicated when someone becomes older and more dependent. You are always your mother's son or father's daughter. Growing old makes people cranky—you hurt, you can't drive anywhere, and people you don't know at all call you "sweetie." Your children are now telling you what to do, and you're powerless to do anything about it.
Adults 65 years or older constitute the fastest-growing segment of the population.2 Current estimates predict that, in the year 2020, 1 in 6 Americans will be in this age group and 15% of older adults will be older than 85 years.2 By the year 2040, the number of people 85 years and older will triple to 14 million.3 Let's face it; there's a major problem lurking in our future. There aren't going to be enough beds in assisted living facilities for those who need them, nor enough health care personnel to provide the care. The PCMH model is an excellent step toward coordinating care. It is crucial that we begin seriously planning now to ensure that the "home" includes home care. JAAPA
Sarah Zarbock is the editor in chief of JAAPA.
REFERENCES
1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf. March 2007. Accessed March 8, 2011.
2. Hobbs FB. The elderly population. US Census Bureau Web site. http://www.census.gov/
population/www/pop-profile/elderpop.html. Accessed March 8, 2011.
3. Stone R. Long-term care: Coming of age in the 21st century. http://www.familyimpactseminars.org/s_wifis12c01.pdf. Accessed March 8, 2011.