Old and Sick in America: The Journey through the Health Care System

By Muriel R. Gillick | Go to book overview

CHAPTER TWELVE
Now and Then

Five years after completing fellowship training in geriatrics, I took care of nursing home patients for the first time. Not very many patients, but a few at each of several different Boston area nursing homes. The idea was that, together with my partner (also a fellowship-trained geriatrician), I would provide a modicum of continuity for patients cared for at the hospital where we were on the medical staff. Primary care physicians at our institution, like physicians everywhere, did not continue to care for their patients once they entered a nursing home. Along with giving up their home and their independence, most older people who moved into a nursing home also had to give up their doctor. With our approach, my partner and I would pick up where our colleagues left of. We would take over the records. We would (sometimes) get a handof from the patients’ long-standing physicians. And the patients would at least retain a relationship with the hospital where they had previously received care.

The contours of my role were defined by government regulations and by allowable Medicare reimbursement. I was expected to visit a new admission to the nursing home within three days of her arrival—even if she was transferred from a hospital and had been seen by a physician as recently as the day of transfer. Then I was to make a return visit every thirty days for three months, after which I was to reduce the frequency of my visits to one every ninety days. If, in the interim, my patient was hospitalized, the clock was reset and the process started all over again. And if, between scheduled visits, my patient got sick, I wasn’t expected to examine her. In fact, I was strongly discouraged from doing anything other than either telephoning in an order, say for an antibiotic, or requesting that she go to our hospital’s emergency room. It wasn’t cost-effective for me to travel to the nursing home to see one patient, and I couldn’t do very much in the way of diagnosis without access to a good deal more technology than was available in the nursing home, so I might as well just ship the patient out. Or so I was told by hospital management.

I learned a good deal about nursing homes in my first few months as a nursing home physician. I discovered that the facilities that looked the nicest, the ones with the grand piano and the coffee shop in the lobby, tended to provide mediocre care: nobody ever played the piano, the only people who

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Old and Sick in America: The Journey through the Health Care System
Table of contents

Table of contents

  • Title Page iii
  • Contents vii
  • Prelude ix
  • Abbreviations in the Text xxi
  • Part I - The Office 1
  • Chapter One - Going to the Doctor 3
  • Chapter Two - The Lay of the Land 23
  • Chapter Three - From the outside in 41
  • Chapter Four - The March of Time, 1965–2015 61
  • Part II - The Hospital 79
  • Chapter Five - Entering the Palace of Technology 81
  • Chapter Six - The Varieties of Hospital Experience 97
  • Chapter Seven - The Hospital through Other Eyes 113
  • Chapter Eight - The Transformation of the American Hospital, 1965–2015 133
  • Part III - The Skilled Nursing Facility 151
  • Chapter Nine - Going to Rehab 153
  • Chapter Ten - Different Snfs, Different Miffs 169
  • Chapter Eleven - Movers and Shapers 184
  • Chapter Twelve - Now and Then 202
  • Finale 223
  • Acknowledgments 245
  • Notes 247
  • Bibliography 267
  • Index 293
  • Studies in Social Medicine 301
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