April 01, 2011

 

By Sam W. Downing, MD, CMD

Flexibility is the key to my life as the medical director for Good Samaritan Society’s home health and hospice in Prescott, Ariz. Adjusting to acute patient needs, case-manager urgencies, and new admissions feels a bit like triaging in an emergency room at times, but it also is what provides me with daily excitement and challenge.

We cover four small towns in an area encompassing almost 1,000 square miles. Our program is small but growing rapid­ly. We began home health services about 5 years ago and hospice services about 3 years ago. Our home health census is typ­ically 60-80, while our hospice has 30-40 home-based patients and a beautiful new 10-bed Hospice House, which opened in the summer of 2010. Perhaps some de­tails of my daily work as medical direc­tor in this community LTC setting can give you insights into what might be in
your future as our aging society inte­grates facility-based services with com­munity-based assisted living, independent living, and extended care.

 Working Together

<[stk -1]>My service to home health is mostly su­pervisory and consultative, with compe­tent nurse case managers and a team of physical, occupational, and speech ther­apists taking their marching orders from local attending physicians. I give advice and offer management suggestions, edu­cational support, and, when needed, physician-to-physician communication concerning clinical and regulatory issues.<[etk]>

Hospice is a different story, as I am much more involved in direct patient care and pain and symptom manage­ment. Our team is composed of RNs, LPNs, social workers, chaplains, certified nurse assistants, bereavement specialists, and volunteers. They all strive to provide high-quality care as patients and families cope with end-of-life situations that are often hard to imagine.

Some cases can be heartbreaking, but many remind us of the richness of life. Recently, a couple celebrated – with us – their 77th wedding anniversary while she was in hospice. When she died soon after, comfortable in her own home, her husband and daughter were at her bed­side. Such stories are almost a daily part of this work.

Interdisciplinary (IDT) meetings are even more critical, I believe, to both hospice and home care than they are to nursing home care. This is where we re­view each patient and family situation and develop and adjust care plans to im­prove the quality of life for patients and families alike. All staff are encouraged to provide input and suggestions relevant to each family’s needs.

We recognize patients and families as delicate units, where even a small shift in care needs can topple the tower of emo­tional, physical, financial, and spiritual resources. Since our inpatient hospice opened, it has been helpful to have that level of care available when the home setting is no longer the best place for a loved one. Hospice House is certified for general inpatient care.

 Home and Family

<[stk -1]>In my consulting role beyond IDT meet­ings, I review medication lists, advise treatment adjustments, sign care plans, give physician orders, write prescriptions, and schedule home visits. Patient and family rounds in the Hospice House of­ten get squeezed in as well, and depend­ing on inpatient census, may require more time than the schedule has allotted. <[etk]>

The patient and family needs I find when I make rounds each day are un­predictable. Without the dedicated team that we have, these challenges would overwhelm a doctor in both complexity and time. Clinically, I rely on my team members just as they rely on me.

Usually, home visits make up my af­ternoons. This is one of the most satis­fying and unique experiences I have had as a physician. Having spent 10 years in private family practice and now 17 years doing hospice home visits, I honestly prefer the latter.

There are few circumstances where we can witness patient and family dy­namics more honestly and accurately than in a home. The old medical bag I carry is sometimes more symbolic than useful, as much of the really helpful in­formation I glean from home visits is in observing and listening when patients and families share their stories. Each pa­tient experience provides new learning and growth for me professionally and personally, and I am grateful to have this opportunity.

<[stk -3]>Throughout my “usual” day, the pager sometimes buzzes endlessly. New admis­sions, possible consults, prescriptions needed ASAP, and assorted patient ur­gencies demand my attention. I have found I can help the nurses optimize their efficiency if I can be readily available for patient management issues as they arise. <[etk]>

 Nursing and Administrative Tasks

Hospice and home health nurses func­tion largely independently in the field, so they need to have solid clinical assess­ment skills as well as an ability to for­mulate a plan of care. They also need to have the ability to communicate their findings clearly and in an organized way, so as to get what they need for their pa­tients in a timely manner.

These are skills that not every nursing home–based nurse has. As medical di­rector I am responsible for medical care and orders for patients but I also play an important role in helping nurses and other staff develop their clinical compe­tence, intuitive abilities, and communi­cation effectiveness. This is both challenging and rewarding as staff blos­som and develop their own styles of ex­cellence and caring.

<[stk -1]>Administrative and leadership meet­ings sometimes seem to clog up my work schedule, but they allow me to have input into program direction and sup­port. I’ve learned to appreciate a well-run meeting that sticks to an agenda and ac­commodates my time constraints.<[etk]>

As my day concludes, I try to com­plete any lingering phone messages or documentation needs. I often do a quick review to ensure that most of the loose ends are tied up, in hopes of decreasing any after-hours calls or crises.

On most days, I also check tomor­row’s schedule and smile, knowing that what shows up on paper today may not really resemble what tomorrow will be­come. But I can honestly say that this work is both personally and profession­ally satisfying.<[qm]><[stk -82]><[scs 115]><[etk]><[stk -1<[etk]>

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<[stk -1]>Dr. Downing is medical director of the Good Samaritan Society’s home health and hospice in Prescott, Ariz. Board certified in family medicine and board eligible in hospice and palliative care, he also is a credentialed HIV specialist. Bill Kubat, LNHA, director of mission integration for the Evangelical Lutheran Good Samaritan Society, coordinates this column.<[etk]>

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