Can’t Get Clean

The network is stepping up its game.

They have elected to participate in a pilot program with the state-funded (and federally subsidized) Medicaid insurer, whereby they will no longer charge the state on a fee-for-service basis. Instead, they will receive a single bundled payment for an episode of care that will last from the date of the patient’s hospitalization through the end of the third month of the patient’s care. Essentially the insurer is incentivizing the network to provide quality and cost-effective care; if they are successful, the network gets to keep a portion of the savings. The problem in implementing such a plan is this: the Medicaid population is (historically) the sickest and least “compliant” population with the greatest number of comorbidities. In short, the Medicaid population features the network’s most complex patients.

“All we are doing is spinning our wheels deeper into the mud,” I said. We all know that the strongest risk-factor for nearly each costly condition in that population is the exact reason (which we have no influence over) that Medicaid is their insurer to begin with: they are poor,” I said to a colleague.

“Yeah, but they keep making their own bad decisions…what are ya gonna do?” he asked.

“How can you expect an individual to make decisions that mirror your own values when they are raised in a hopeless environment built on a foundation of inherent inequality? This reminds me of a conversation (last year) that I had with my grandfather (an old “southern gentleman”) and my father. My dad is a right-leaning would-be Trump voter who is quick to complain about how folks won’t pick themselves up by their bootstraps, how communities don’t take their streets back from gangs, and fails to understand why many people in the urban community don’t value a high school education. My grandfather was sharing an experience that he had when walking downtown in the mid-nineties when he walked by the soup kitchen. The line was out the door and he vividly remembers a teenager standing in line with a small boy; he thought to himself, ‘With that boy as a father, this kid doesn’t have a chance.’ My father raised his hands in frustration, ‘See? Exactly!’ he said. ‘This is what I am always talking about…they are just takin’ my money without workin’ a lick, and then their kids don’t learn how to do shit, either.’ [my colleague nods his head in agreement]. To which, I turned to my father and said, ‘Yeah, but [assuming that the teenager was a father and not a sibling – which I took issue with] if your assumptions are correct, then when you walk by that same soup kitchen today, that boy who didn’t have a chance almost twenty years ago has now grown up and may be in the same line with a child of his own. If he didn’t have a chance back then, why do you look down on him today?'”

My colleague looked at me in the eye and grinned: “That’s why I’m all for population cleansing.” My eyes widened. “Hey – keep in mind – I said ‘population cleansing’, not ‘ethnic cleansing.'”

Perhaps it was just an unfunny joke, but I preferred my father’s response: “Jesus christ, Keith, you know it’s more complicated than that.”

My father wasn’t funny, but he was right. It’s way more complicated than that.

Commentary: Unenviable

After my recent posting, Unenviable, a conversation began on Facebook that I wanted to share here. Perhaps it might add additional perspective to my initial posting.

JD: This woman could be dying of inter-spousal stress infliction. On top of the aorta problem I mean..

AR: So could he, JD.

JJ: Maybe, but she’s the one who weighs 84 pounds. And had to go to hospital.

AR: Yeah, I get that, but what is the dynamic that leads to resolution. People get tired and we start to pick what team jersey to wear and it doesn’t lead to resolution.. It is a huge part of chronic conditions and is essential to moving forward.If you pick sides, life is easier, but not more effective. What they don’t need is more tears.

HS: I can’t think of a single excuse to yell at another human like that. Or any thing.

This is the type of dialogue that I was hoping would be elicited from the posting. Much of the sentiment expressed was very much in-line with my own natural thoughts the day that Lydia went to the hospital. The following is my own response in the conversation.

 I appreciate the dialogue regarding this interaction. And while I agree with HS that I (personally) can’t think of an ‘excuse’ to yell at someone like that, under those circumstances – I tried not to pass judgement (in the home, or in the posting).

I was in the home for Lydia, so she is my one and only concern, whether I agree with her or not. In this instance, I HAD to call 9-1-1 (by policy), but I knew she wouldn’t go – after all, she had already refused to go to the hospital the week before. So despite my desire to be a ‘good libertarian’ and do what SHE wanted, I knew what was in her best interest and sat down to convince her that what I was going to have to do (as yet unbeknownst to her) was something that she wanted and needed. I was thrilled when my poor-man’s version of motivational interviewing had paid off – (1) there is nothing worse that wasting tax-payers dollars to bring out the EMTs when the patient has already stated that they won’t leave but I have to call anyway due to policies designed to cover the agency’s ass and (2) she REALLY needed to go (more than I knew at that time).

The husband was upstairs when the decision was made; their daughter had walked upstairs to inform him that he was going to have to go to the hospital with his wife. It was then that he came down and said all that has been written. Some thoughts:

(a) This is a lower-middle class family – a sometimes gruff blue-collar group who has lived and worked hard – the use of ‘fuckin‘ as an adjective is quite possibly used between the 2 parties in good times and in bad. I try not to judge the use of ‘fuck‘ more than I do ‘ain’t‘- regardless of context (this is, of course, difficult).

(b) If we look at most of the phrasing, without the cursing and with a pet name thrown in, he might be trying to motivate and compel her to get better: “Come on, hon, get up! This is ridiculous, show us what you can really do. You need to be stronger, sweetie. You need to stop trying to have everyone else get you better. You were just at the hospital – you are fine!” Maybe he just really loves her and it pains him to see her this way. Maybe he doesn’t have the skills or capacity to convey that to her. I don’t know. I may doubt it, but I don’t know.

(c) It seems that he is struggling to say something that might motivate her while coming to grips with his own frustrations: “You keep doing this to us. You keep wasting our time with this…You were just at the hospital – you are fine!

So maybe you had a man’s gruff, unrefined vernacular coupled with his love for – and desire to motivate – his wife while simultaneously being unable to filter his own thoughts/emotions in a stressful time – mashed together with no medical knowledge of how quickly a change of condition can present.

Or maybe he is a fucking asshole…of course, that is likely a false dichotomy and the truth lies somewhere in between. Perhaps, if I had observed their marriage before now, I would know better; for now it is just fuel for thought.

The other thing that keeps going through my head (as I also mentioned to a reader on Facebook) is the potential similarities between Lydia’s experience and the patient who might be receiving outpatient PT for chronic low back pain who has been on disability for 3 years. Might the stresses be similar at his/her home? What kind of support system is in place after they leave the clinic, with its environment that has (hopefully) been so carefully crafted to optimize benefit for the patient?

Most teachers understand that they only have influence over a child 6-7 hours per day, 5 days per week, for less than 9 months per year (in the US). They understand that no matter what they do in the school, the child is going to shaped most by what happens the other 18 hours of the day, not the time spent in school. How many therapists consider their own influence as realistically when they send their patients home after a bi-weekly 30-minute therapy visit?

What would a single consultative home visit provide the clinician that a visit to the clinic can’t? What if the entire family and support system for the patient were included in that single consultation, outlining a plan, collaboratively, to provide the patient with a realistic support system that will work for all family/friends who share their time together the other 167 hours of the week that the patient isn’t in the clinic?

In thinking back to Lydia, I wonder what may have happened if I had asked the husband (who, I hadn’t yet met, and wasn’t even aware if he was/wasn’t home) to come down while Lydia and I were discussing the ambulance. Would he have responded differently? Would she have decided differently? Would she be dead, or alive? Did I ‘wrong’ the husband in some way by unintentionally not involving him, making him feel like he had diminishing control? Might some of his frustrations with me been re-directed at her. As it was, the stakes were high for Lydia; I am just glad that things worked out…

…but I can’t stop thinking about that day. It has a lot to teach me.

Unenviable

“What the hell do you think you’re doing?”

Lydia was recently discharged to home after her second cardiac surgery. The first one, 2 years ago, kicked her ass. Since that time, she has slept alone on the first floor of her home, while her husband still sleeps in their bedroom upstairs. She hasn’t been able to walk up/down stairs without assistance since her initial surgery, which is unfortunate considering that she has to climb 20+ steps from the sidewalk to enter her home. She is, without a doubt, homebound.

“You don’t want to get better!”

My first visit, the Tuesday before last, was cancelled. When the nurse had visited earlier in the morning, Lydia was short of breath and reporting severe abdominal pain. The nurse called emergency services and the EMTs arrived to the home. Lydia sent the ambulance away empty. She remained in her own bed. I would have to wait to meet her.

“You won’t even try to help yourself and get outta this fuckin’ bed!”

Six days (and another nursing visit) later, I finally had an opportunity to meet Lydia – she was exceedingly frail and very weak. She was spending ALL day in bed, lying supine. She fell backwards into my arms 2 times when walking 10 feet to her bathroom, refusing to use a walker for support. Her pain was reduced compared to the week before (6/10) and she expressed an interest in trying to regain some of the strength that she had lost during multiple months of hospitalization as she battled an infection and multiple surgeries (yes, there were others). I arranged to visit again on Wednesday, 2 days later.

“You were just at the hospital – you are fine!”

When I returned on Wednesday, she looked worse. She was lying on her side with her knees curled up to her chest. She was weeping. Her pain was a 9/10 and it was constant, unremitting. She could not find a position or movement to reduce or alter the throbbing pain in her abdomen. I had to call the ambulance, but I asked for to consider going to the hospital before I placed the call.

“Come on, get Up! This is bullshit!”

She told me that she had been considering going to the hospital, but was thinking that she might just be constipated; she preferred to stay home for the night, drink some prune juice and take a stool softener – she would go to the hospital tomorrow if she still felt as bad the following day as she did at the time of my visit.

“Show us what you can really do!”

For 10 minutes, I sat at her bedside. She shared with me why she wanted to stay home. She had been in the hospital long enough already. She would miss her grandson, who lived with her. While empathized with her predicament, I reminded her of the severity of her symptoms and the limitation of home health care in addressing her needs. Easter was only 4 days away; surely she wouldn’t want to wait until then to go the hospital if she could be in and out earlier, I told her.

It took a little bit of time and effort, but she changed her mind and committed to going to the hospital for an assessment.

“You need to be stronger and stop trying to have everyone else get you better!”

I called 9-1-1. Lydia’s husband of 42 years yelled and screamed at her as he collected her identification, medication list and insurance cards.

The ambulance arrived. The EMTs pushed her out the door. They carried her down 20+ steps to the sidewalk. They placed her in the ambulance. They closed the door. They drove her (and her husband) away.

“You keep doing this to us. You keep wasting our fuckin’ time with this shit!”

The next day, I received an appreciative call from the nursing case manager with the agency…thanking me. It turns out that if I hadn’t convinced her to go the hospital, Lydia likely wouldn’t have been available for my next visit – she was found to be septic and bleeding internally when she arrived to the hospital.

I checked the obituaries today, now 4 days later; I don’t see her name yet.

I wonder what her husband has to say about that.

Inadequate

“Hey Chuck, Happy Veterans Day, man. Thanks again for…well…for everything*.”

A handshake and a one-armed hug just doesn’t cut it.

 

 

*Disclaimer: ‘Everything’ entails: missing out on the 1st and 4th years of your first born’s life as well as the 1st year of your second’s, nearly destroying your marriage, suffering through the unimaginable, coming home a shell of your former self and tolerating the flashbacks while you attend my son’s 6th birthday party at an all-too-noisy bowling alley.

 

Sundays With Family, Pt. 23

In 1993 – as a Junior in high school – my teacher asked the class to write a paper on their version of the ‘American Dream’. The radio stations were playing Ugly Kid Joe, and although I had never heard of Harry Chapin, my dream had already been shaped. My goal wasn’t to provide my own family with more than my father had provided his; my ‘American Dream’ was to provide the same things more easily.

My father was (and still is) a working man’s man. With only a sub-standard high school education coupled with a lot of practical know-how and a strong work ethic, he has since worked his way to a very comfortable life for he and his family. He paid a price for this comfort, however, and even at the age of 16 years, I understood what the job had done to him.

When you comin’ home, dad, I don’t know when, 
But we’ll get together then, Son,
You know we’ll have a good time then.

While I was wearing new sneakers (riding the pine for the basketball team), he was working the night shift. When I was at school, he was waking up to split wood, maintain the house, mow the lawn, repair the cars, or work on the tractor. When my mother was driving me across 4 counties in a weekend to play 3 different ice hockey games, he was working overtime. When at camp learning about astronomy, my father was struggling to spend, earn and save more money simultaneously.

Dad just did what Dad had to do so that I could do what I wanted to do and become who he wanted me to be.

And the cats in the cradle and the silver spoon
Little boy blue and the man on the moon

AJ is in first-grade now, but we continue our tradition from kindergarten, still. Two days ago, while we were eating our ‘usual’ meal as ‘regulars’ in ‘our booth’, the radio was playing Harry Chapin and I smiled. This week, I took AJ to a doctor’s appointment, made his lunch before school, walked with him to the bus stop every morning, went to his swimming lessons, read to him at night, listened to him read to me during the day, took him to the playground (twice), went for a hike at a local state park and – now – we were eating breakfast together before school. Every morning he wakes up in a very comfortable home and (like his father before him) doesn’t want for anything. When I considered all that my week had entailed, I smiled as I raised my coffee cup to my lips.

I am living my American Dream.

Glass Half Full

Her mother has twice had lung cancer, twice she has had a lobe removed from her lung…

“Just so you know,” my wife said to me before going upstairs to complete my paperwork, “my mom had a hot spot on her last PET scan.”

“Really? Where?” I asked.

“Her lung again. But it probably isn’t anything to worry about…this has happened before too. Usually it is just a hot spot or some inflammation that shows up and the biopsy ends up negative.”

“Okay…how many times has a scan found something?” I inquired.

“Four.”

Implausible

It was time…AJ now has his expander (he calls it his “smile-maker”).

The pediatric dentist/orthodontist had just finished putting AJ’s appliance in and my brave and uncomfortable son – with gums bleeding (only slightly, but it sounds dramatic, no?) – was choosing from a pile of Disney stickers for a prize when the the dentist turned to me and said:

So, to review: swallowing is going to be different for him for a few days. Just eat soft, slippery stuff – ice cream, applesauce, yogurt – stuff like that…until he gets used to the smile-maker. Nothing sticky like gum, taffy, or tootsie rolls. Be sure to brush not just the teeth, but be sure you get any food-stuff in the smile-maker as well.

I nodded with approval as AJ selected a Finding Nemo sticker and the dentist turned toward his chart before abruptly turning back to add:

Oh, and be certain to brush his tongue; it is going to be pressed against the roof of his mouth (and the smile-maker) all day so it can become indented. So, be sure to brush the tongue hard when you brush his teeth so that you toughen up the tongue to to prevent it from getting too indented by the smile-maker.

As I left the office, I wondered how many parents would be scrubbing their child’s tongue tonight, wondering if they were doing it hard enough.