Home visits give doctors insights into obstacles faced by chronically ill

April 1, 2015

It takes a community to care for a patient


Billie Jo Kesso, 43, has been struggling to manage her diabetes and its complications since she was 22. Two years ago, she and her teenaged son moved from Chicago to Phoenix to live with her mother, a retiree.

"I was unable to live on my own but I felt like my disease was suffocating me," she says. "I was afraid to leave the house because I worried about passing out whenever I was alone. But at home, my mother — who had already lost another daughter to diabetes — hovered over me. I was struggling financially and physically, and emotionally I just felt so isolated."

Billie Jo Kesso gets a house call from Dr. Libu Varughese, a second year resident at St. Joseph's Hospital and Medical Center in Phoenix. Varughese says such visits help him "understand various obstacles that hinder patients in reaching the goals you set" for them.

That's when Kesso's mother encouraged her to make an appointment at the Internal Medicine Clinic at St. Joseph's Hospital and Medical Center in Phoenix.

"After 21 years of going to doctors, I wasn't expecting much — just a 10- or 20-minute appointment and then out the door," says Kesso. "But at St. Joe's, I met with a social worker, Chris Barreto, who connected me with all kinds of programs for help with transportation, grocery shopping, individual counseling and even socializing with others coping with the same disease."

That kind of assistance, Kesso says, has completely changed her outlook. "I now feel like I'm controlling my disease, instead of it controlling my life," she says. "At other medical clinics, I always felt like a number. But at St. Joe's, I feel like part of an extended family."

Matching care to needs
That's exactly the kind of outcome St. Joseph's was hoping to achieve for patients when it began its CATCH (Clients Aligned Through Community and Hospital) model of transitional care in 2013 with a three-year grant it received from Dignity Health Foundation's Arizona Communities of Care.

According to Dr. Priya Radhakrishnan, the Robert Craig Chair of Internal Medicine at St. Joseph's, CATCH is based on Dr. Edward H. Wagner's chronic care model, which emphasizes a patient-centered, rather than a disease-centered, model of helping people afflicted with long-term illnesses like diabetes and congestive heart failure.

Wagner directs the MacColl Center (formerly the MacColl Institute for Health Care Innovation) at the Group Health Research Institute in Seattle. He maintains that a growing number of people suffering from major chronic illnesses face many obstacles in coping with their conditions, not the least of which is medical care that often doesn't meet their needs for effective clinical management, psychological support and information. There is a mismatch, he says, between their needs and U.S. care delivery systems that are largely designed for acute illness.

"We need to be thinking about Mrs. Jones not as a diabetic, but as Mrs. Jones who has diabetes," explains Radhakrishnan. People, she adds, do not live in clinics, but in homes, neighborhoods and communities, where care should be coordinated between providers and services.

Teaching doctors compassion
Radhakrishnan, along with Joseph Switalski, chief of business expansion at the Foundation for Senior Living in Phoenix, will present a breakout session on the CATCH model at the Catholic Health Assembly June 7-9 in Washington, D.C.

Unique to CATCH is the involvement of St. Joseph's medical residents (the hospital is affiliated with Creighton University School of Medicine in Omaha, Neb.) in the program.

"There is a huge gap in medical education and delivery of care today," says Radhakrishnan. "We train specialists now — lots of 'ists' [hospitalists, ambulists,] and 'ologists' [cardiologists, hematologists] to take care of patients' problems — but what gets lost in the process is the patients themselves.

"Fifteen or 20 years ago, young doctors made home visits with nurses and social workers," continues Radhakrishnan. "We think it should still be an important part of medical training. We want to create the compassionate doctors of tomorrow, those who see patients as humans with illnesses that require communities to take care of them."

Kitchen table health care
To that end, social worker Barreto acts as the liaison for the CATCH program, making the initial encounter with clinic patients like Kesso. Then he schedules a home visit for himself and a resident to get what Radhakrishnan calls a "360-degree view of patient care."

"There is a much different kind of exchange of information on a home visit, where a patient feels more relaxed even though a clinic resident may not be 100 percent comfortable," says Barreto. "We know the medical objectives a primary care physician has asked the patient to achieve, and then we can see any obstacles to those objectives in the context of the patient's psychosocial environment."

According to Barreto, these are some of the important observations the social worker/physician team can assess: Is there a caregiver in the patient's immediate world who can help dispense medications, check blood sugars, etc.? What kind of food is kept in the refrigerator? Is transportation readily available? Can the patient safely ambulate around the living space? Is the home tidy or are there signs of poor hygiene, hoarding, etc., that may signal mental health issues?

Extending a hand
From there, patients are connected with CATCH community collaborators who can help address obstacles that stand in the way of self-management of disease. A nonprofit organization called Duet: Partners in Health & Aging, for example, matches volunteers providing transportation to clients who need help getting to medical appointments. Catholic Charities Community Services provides licensed counseling for patients and their caregivers and families. And Keogh Health Connection determines public programs for which patients qualify — be it insurance subsidies through the Affordable Care Act, Medicaid coverage or food stamps — and assists them in making applications and tracking them to conclusion.

Most important for CATCH in particular, says Barreto, is that both he and his collaborator at Keogh, Livbier Pearson, are bilingual in Spanish and English.

"Seeking assistance from government organizations can be intimidating for anyone, but when you are from a lower socioeconomic group, either documented or undocumented, and don't speak English, there is a much greater complexity in seeking out health care or food stamps," Baretto explains. "Two-thirds of our CATCH clients are Spanish speakers, so it's important that we can communicate with them and take away the threatening aspect of seeking and obtaining needed resources."

Taking the blame off patients
Medical residents benefit from the experience of participating in the CATCH model as well as its clients do, says Dr. Libu Varughese, a second year resident at St. Joseph's who has cared for Kesso, among other patients.

"It's easy to become frustrated when, as a doctor, I feel that a patient doesn't listen to what I say about caring for their disease. You begin to think, 'This person is not interested in their own health, so what's the point of trying to help them?'" says Varughese. "But after making a few home visits, you can begin to understand various obstacles that hinder patients in reaching the goals you set. There is a huge disconnect between physicians and some of their patients' realities."

That realization has led CATCH residents to eliminate the label "noncompliant" from their lexicon, Radhakrishnan says.

"If you tell patients to make a follow-up appointment in a month — and then through a home visit you realize they have no transportation or have no money to pay for transportation — you realize the issue isn't noncompliance. The issue is learning to connect the dots to enable patients to take part in their own care," she says.

With initial funding for CATCH due to expire at the end of 2015, Radhakrishnan says St. Joseph's is hoping to continue it as an ongoing part of the medical center's operations.

"The CATCH model fits right into our mission of stewardship and compassionate care," she says. "It allows us to conserve resources by providing long-term continuity of care at lower cost than having patients access short-term, high-cost care through the ER. It teaches our doctors the values of human kindness. And it allows our patients with high burdens of disease to live lives full of dignity."


Copyright © 2015 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2015 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.