Academic journal article Care Management Journals

In the Life: A Case of Autonomy, Exploitation, and Undue Influence in Geriatric Home Care

Academic journal article Care Management Journals

In the Life: A Case of Autonomy, Exploitation, and Undue Influence in Geriatric Home Care

Article excerpt

How Come?

You ain't my brother now

I don't trust the way

You stamp your feet on me

I don't shine up

To this devil-goosin' stuff

You been layin' on in my behalf

Oh you ain't my lovin' buddy now

Sometime I think the manner

You come in my house

And dirty-arm me around

Is something I don't particularly cherish

Kenneth Patchen

Hurrah for Anything ( 1957)

UP IN THE OLD HOTEL

Mr. G was an 88-year-old man who lived in a single-room occu- pancy (SRO) residential hotel in New York City (NYC). This hotel was once a traditional SRO for short- or long-term stayers but is now run by a privately funded social service agency as a low-cost residence for independently living adults older than 55 years. Many are formerly homeless and were referred by the NYC Department of Homeless Services, whereas others were marginally housed and referred by community agencies. Mr. G was a self-referral and had lived quietly in the same room for 24 years.

There are about 275 residents in the building, in a colorful cross- section of NYC life, ranging from self-described "Bowery bums" to blue-collar workers and secretaries to professional dancers, musicians, and artists. Each room has its own bathroom but no kitchen. The hotel provides weekly housekeeping, two low-cost meals a day in its cafeteria, and social work services by a staff of six. Monthly contact with a case manager is required, as is a home visit every 6 months, but finances are not routinely monitored. The hotel also sponsors activi- ties such as exercise and crafts classes, entertainment and outings for residents, and features a library and computer room, TV room, and drop-in center for homeless older adults.

The Department of Community Medicine, founded in 1969 at the former St. Vincent's Hospital and now under Lutheran Family Health Centers, has run a small part-time clinic at this hotel for more than 30 years, caring for street homeless and the hotel's residents alike on a walk-in or ongoing basis. The team has known many residents for years, beginning in shelter clinics and the hospital-based SRO clinic, and once patients are housed, continuing care at the hotel. Some become homebound, requiring home visits, a visiting nurse, and even hospice to enable them to remain in their precious and hard-won rooms. Some attend weekly for medication management and checkups. Our team is made up of a nurse, a social worker, an outreach worker, and a physician, who all work at other program sites as well, and we see about 25 patients a week. The physician is a graduate of Mt. Sinai's medical school and the St. Vincent's internal medicine primary care residency; the clinic currently hosts Mt. Sinai medical students.

The Patient

Mr. G was first seen in 2002 for a flu shot and a pneumonia shot- he denied depression, declined medical care, and did not respond to recall slips and outreach visits. He next came in 2003 for a flu shot given by another physician. In early 2007, he was brought in by the social work supervisor and saw the nurse. He had been scheduled for cataract repair at New York Eye and Ear Infirmary, but did not go, feeling nervous. He did not return to follow up with the doctor. In the spring of 2007, his case manager came to ask if we could bathe a resident-we suggested an aide and to bring the resident in-later this turned out to be Mr. G.

A new case manager joined the staff, made a home visit, and brought Mr. G to clinic in May 2007. He said that he had fallen recently and gone to the Cabrini Hospital emergency room (ER). Records showed that he was at the scene when EMS came to the hotel for someone else-he was taken in as well because he was leaning against a wall and "he didn't look good" per the notes. He left the ER against medical advice "to follow up with primary care doctor" after being told that his chest x-ray showed a lung mass. Now he wanted us to find the results of "the x-ray of the spot on the lungs. …

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