Linda Martinez, R.N.
It may sound like a tired truism, but a picture really is worth a thousand words, especially when it comes to seeing patient care in action. That’s what I learned when in Albuquerque earlier this month doing reporting to support my September cover story on population health (which will appear online in the next several days).
I had already interviewed the wonderful folks at Presbyterian Health Services regarding Hospital at Home, the groundbreaking program that they were the first to execute on outside the VA health system, based on a brilliant concept by Johns Hopkins medical researcher Bruce Leff, M.D.
But since I was in traveling in New Mexico earlier this month anyway, I wanted to take the opportunity to meet some of the Presbyterian Hospital at Home team members while there. I was able to meet Elizabeth Ward, M.D., Melanie Van Amsterdam, M.D., and Linda Martinez, R.N., the three lead clinicians in the program, as well as Darren Maestas, R.N., the program’s patient care manager, and Karen Thompson, its director. Every one of the team members is tremendously passionate about what they’re all doing, and immensely dedicated to making this truly innovative program succeed. Not surprisingly, early results are showing impressive gains in clinical outcomes, patient satisfaction, and cost-effectiveness.
But to really understand what a program like Hospital at Home—which effectively bridges the gap between inpatient hospitalization and home health care in a very ingenious way—is really like, it’s necessary to go on a patient visit with one of the clinicians.
So on a bright New Mexico morning earlier this month, I drove out to a rather remote neighborhood in the sprawling Albuquerque metropolitan area with Linda Martinez, R.N., and watched as she conducted a very thorough clinical visit with an 82-year-old patient I’ll call Mr. Smith, in his home. Mr. Smith is in end-stage COPD, after a lifetime of smoking (in fact, he’s still a chain-smoker; and his wife, who passed away from COPD last year, was a lifetime chain-smoker as well). Let’s put it bluntly: Mr. Smith is not doing well these days. When Linda asked him to walk across the floor of his living room and kitchen in order to observe and calculate his oxygen capacity (and of course, Linda followed him very closely, walking about one step right behind him the entire time), Mr. Smith was able to walk maybe 20 or so tiny steps before he had to sit down on his couch again. (He basically spends his days on the couch, connected to a large oxygen machine a few feet away, and, yes, smoking the whole time.)
During the comprehensive visit, there were moments when I was able to converse a bit with Mr. Smith’s adult daughter, a woman in her late fifties who is not only caring for her father full-time in their mutual home (and she cared for her mother during her last years as well); she’s also caring for two twin toddler grandchildren and six dogs. Mr. Smith’s daughter can’t say enough good things about Hospital at Home. As she pointed out, for her father, an inpatient admission is hugely disruptive, and so far, all the clinical interventions needed in the past few months, as Mr. Smith has been admitted several times to Hospital at Home, have been very effectively managed and executed in the home setting, and for that, she and her father are both very grateful.
Obviously, a situation of extreme acuity or involving certain complications would trigger an ambulance drive to Presbyterian Hospital in downtown Albuquerque; but the reality is that, for many patients with chronic illnesses like congestive heart failure, diabetes, renal failure, and COPD, most of what can be done for them clinically can very effectively be accomplished in the home, using the pattern of once-a-day physician visits, twice-a-day nurse visits, and intensive phone triaging and care management in between. Indeed, they generally heal better in the comfort and quiet of their homes, and are far more compliant with clinician instructions, partly because they and their family-member caregivers are listening to those instructions in a far less disorienting place than a discharge cubicle in a noisy, busy hospital. And not only are the outcomes often better, the patient satisfaction skyrockets as a result, and of course, the costs end up being a fraction of what they would be for inpatient hospital admissions. So it’s a win-win for everyone.
In fact, this particular visit is transitioning Mr. Smith from Hospital at Home back to home health, which is a continuous part of his life now. So I’m witnessing a complete clinical evaluation and also a discharge, though this discharge takes place on Mr. Smith’s living room sofa, with a very detailed and comprehensive discussion among Linda Martinez, Mr. Smith, and his daughter, around his condition, medications, and other topics. And I’m frankly amazed at the level of clinical understanding of the adult daughter, a woman who is not well-educated in the traditional sense, but who has become, in a limited way, a clinical expert on COPD, as she’s been the main family caregiver both for her recently deceased mother, and for her father, over the past few years.
On the long (about 35 minutes) drive to and from the Smith home, Linda and I have fantastic conversations about the program and what it means to patients—and to clinicians. Linda is a clinical nurse specialist with prescriptive authority; in New Mexico, that means that she works at the same level as nurse practitioners, and is able to use her 25 years of patient care experience to the highest level of her licensure. Linda tells me that she absolutely loves working with Elizabeth Ward and Melanie Van Amsterdam, physicians who share her vision of multidisciplinary, collaboratively executed, team-based patient care; and of course, she loves working with the other clinicians and administrative staff on the team, too.
Most of all, Linda derives great satisfaction from knowing that her work in Hospital at Home is improving patient outcomes, while lowering costs, and very dramatically improving patient—and family caregiver—satisfaction. What could be better?
The reality, we agree, is that as the incidence of chronic illness in the U.S. population explodes in the next decade, healthcare leaders are going to have to find new ways to optimally deliver care; and for a certain percentage of patients, under the right clinical and care delivery circumstances, the Hospital at Home concept is perfect.
There is great personal satisfaction, too. “It’s wonderful to be able to really spend time with these patients, to get to know them, to understand the context in which they live and in which they live with their conditions,” she says. “And the result is better outcomes for them—and really, for their families, too.”
And isn’t that exactly where the healthcare system has to move in the near future, anyway? The old volume-based fee-for-service system, which rewards providers for waiting until patients’ conditions become highly acute, is clearly unsustainable, not only economically (with Medicare spending expected to double within the next decade), but even societally, as millions more Americans fall prey to chronic illnesses every year. With the huge increase in the number of Americans who will be able to access health insurance now thanks to the Affordable Care Act, our healthcare system doesn’t even have the clinicians to serve the needs of many of the newly insured, even if we had the Medicare money to do so.
So I think it’s time for more of us to study the example of healthcare pioneers like Linda Martinez. What she and her colleagues are developing and executing at Presbyterian Health Services in Albuquerque looks a lot to me like one important piece of the future of healthcare delivery in this country. And seeing how all this plays out at the individual patient level, in a patient’s home was definitely a picture worth well over a thousand words.
