Home care.

Megan McArdle has a piece on healthcare cost-cutting and hospitalization stay-length:

If you've been wondering about the rather light posting schedule, here's most of the explanation: two Saturdays ago, my mother's appendix burst.  It was a lengthy, draining saga that fouled up a rather full writing schedule.  We just brought her home from the hospital today; she'll be staying with us while she finishes a course of IV antibiotics.  Luckily, we're both writers with a great deal of flexibility about where we can work, and we have a spare bedroom, and the means to purchase a bed for her to stay on.

...Hospital costs were a huge political issue throughout the 1970s.  Jimmy Carter unsuccessfully tried to pass price controls, but ultimately, the government settled on a system that paid a fixed reimbursement for a given class of problem, rather than just paying the hospital for however long they'd care to keep patient. (A system known as Diagnostic Related Groups, or DRGs).  The length of hospital visits dropped like a stone--from an average of 7.5 days in 1980 to 4.8 today.  Most of that change was accomplished by 1995.

I know all the reasons why this is a good idea.  Hospital days are unbelievably expensive.  And hospitals are not fun places to be.  They're noisy and the amenities aren't too great.  They're also a great place to pick up a hospital acquired infection--and hospitals are the primary vectors for really nasty drug resistant bacteria.

 

But it's hell on the families--the web is full of people who are at their wits end because the hospital just dumped Mom on them even though Mom can't really walk or use the toilet.

...One way to think about it is that we made a policy choice to save money by turning family and friends into parahealth professionals.  In my case, I think that's the right choice: I'm happy to take care of my mother, and I understand the cost pressures that made this desirable.

 

  The problem is, most people didn't participate in that choice.  There was no public debate over whether we should send elderly patients home in terminal condition to families with no training as health workers.  We just said "let's cut hospital costs!" and everyone said "Yay!" and then some folks in a back room decided that this was the way to do it. 

 

So "one way to think about it" is that lately we have "made a policy choice to save money by turning family and friends into parahealth professionals."  Another way to think of it is that, long ago, we made a policy choice to spend money -- and ostensibly to provide better care -- by professionalizing convalescent, hospice, and recovery care, which used to be done (for better or worse) by family members.

 

This doesn't purport to be an argument for or against insurance coverage of longer hospital stays, just a musing on some unintended consequences.

 

I have no doubt that a lot of people would be better off cared for by hospital staff than by family members.  And many people have no one to care for them at all.  

 

But I think it's worth remembering that "sickroom care" was once a natural part of homemaking, and families used to have the skills to care for relatives who were suffering from a wide variety of ailments.  We're talking about something that is a lost art, not an impossible art.  Old homemaking manuals used to have chapters about it (here's one); sometimes even cookbooks would.  There was one around the house when I was a child -- heaven knows where it came from -- and I used to read the "sick room" chapter with fascination -- how to clean and sterilize a bedpan and wrap it in a neat package of clean newspaper to keep it read y for use, and the importance of giving the patient as much privacy as possible (even if that is only turning your face casually away) while he or she uses it;  how many visitors are appropriate; what to do with infectious garbage; how often to change the sheets; how to avoid bedsores.

 

Homemaking manuals don't seem to have this chapter anymore.

 

 It seems pretty obvious that when people grow to expect professionals to do the work of caring for the sick, both the recovering and the dying, then that work is no longer seen as the proper expertise of loved ones.  Either it is above them (and doctors and professional nurses should do it) or it is below them (and health care techs and janitors should do it).  

Maybe one way to lower costs, and improve care at the same time, is to invest in caregiver support rather than hospital stays.  

Is it better that hospital care be available?  Obviously so, at least for many cases.  It's hard, though, not to see some parallels to the home birth movement.  Sometimes people choose to forgo technology, professional health care workers, and a sterile environment, because they have an alternative:  human hands, loved ones who (unprofessionally) love them and desire the best for them, and a familiar home environment.  When it becomes the norm to professionalize a caregiving environment, surely a great many people have better outcomes (especially those who do not have the alternative) -- but there are also a large class of people who won't really have "better" outcomes and who will have lost out on a real opportunity for human connection, human relationship building, the experience of relying on others or of caring for others because that's what human beings do.

Maybe we need a home convalescence movement, or a home hospice movement, the way we have a home birth movement.   (If that's so, then we could use some "midwives:"  experienced and caring, but not necessarily professionally trained and licensed, women and men whose passion is to help people help themselves in their own homes.)  It's surely not for everyone, but it could well be -- for more people than realize it.

UPDATE:  Oh goodness, a McArdle-lanche.  Welcome to my hastily-tossed-off post.  You may be interested in other posts partly inspired by discussions at Megan's blog, many of which are in my weight loss category.  There is also politics (lately material about the HHS contraception mandate) and homeschooling.

Comments

[entropy]

Like.

I have some old homemaking manuals; I wonder if they have sickroom chapters.

[MrsDarwin]

These are excellent points.

My mother convalesced at my home recently -- nothing life threatening, though it seemed almost so at the time. However, for the first five days of her illness, she was in the hospital when I believe she really could have been at my house. Most of the day she lay quiet and bored in bed; once a day the doctor would look at her for about five minutes; the nurses came in every few hours to fluff pillows and take vitals. These were all things I could have done, and would have been happy to do, at far less cost than the hospital charged.

I like the idea of a home convalescence movement.

[bearing]

It's not something that should be over-romanticized; caring for sick people is difficult and stressful (as the old homemaking manuals make clear). But that is almost as much an argument *for* in-home care by loved ones as *against* it.

I think the analogy to homebirth is apt, because that's also something that should not be over-romanticized and is also something that is obviously not for everyone (but just as obviously could be for more people than is currently accepted).

[Rebekka]

Do you guys not have home health nurses/ district nurses there? Here when we discharge someone from the hospital and they are not at their usual level of functioning we have several options, the most extreme being to send them to a temporary rehabilitation (not in the drugs sense) center where there are nurses and physical therapists but not doctors. Otherwise they come home and we talk with the patient and family to figure what kind of support is needed. Sometimes the family is able and willing to do it all, and sometimes there is no family so nurses and nurse aides will need to provide all the help, but it's usually a mix.

Often we have family members who help while the patient is at the hospital - typically parents helping a half-grown child or one spouse helping the other with a bath or with meals.

Laying out the dead is something else though - I'm sure family participation is more frequent when someone dies at home, but I've never had someone even want to be there when we do it.

[bearing]

I'm honestly not sure what is available because I've never had cause to need it. When my mother was dying in 2003 we never got a chance to discuss -- she passed away about 90 minutes before our appointment to talk with hospice.

(Probably intentionally, if you ask me -- she didn't want anything to do with hospice, though she never articulated her reasons to me.)

I suspect that, like so many things, what's available through government social services is a patchwork across the various US states and sometimes cities, and that insurance coverage is also variable in what it does and doesn't cover.

[MelanieB]

I like this idea. And yet it strikes me that for many families it would be virtually impossible without a major economic shift. The biggest problem is that there are so many fewer homemakers today than there were when those old homemaking manuals were written. I feel it profoundly as a stay at home mother. We live in a neighborhood that was built in the fifties. Many of our neighbors are still the original residents. All the neighbors of that generation know each other and I have observed that they are in and out of each other's houses all day long. I get a glimpse of what it must have been like when they were all young mothers raising their families. I bet their kids were in and out of each others' houses all day long too. There are other young families on our block too but I don't know if there are any other stay at hoe moms. Certainly there is no network or support structure. Caring for a sick relative would have been much more realistic an option with neighbors who are there to help, with extended family living either nearby or in the same household. These days households like ours with stay at home mothers or McArdle's with work-at-home couples are the exception. I'd suspect that the majority double-income households can't afford to have one spouse take off weeks or months to care for a convalescent parent.