Project at Home — Bringing Hospital Level Care to the Home
John Krupinsky worked most of his life in a Pennsylvania coal mine and had black lung to prove it.
More than five decades spent inhaling coal dust left him with chronic obstructive pulmonary disease and heart trouble. Confined to a hospital bed in his daughter Rose Zehner’s basement in East Baltimore, MD., the 87-year-old had two pleasures left in life: chewing pipe tobacco and a 13-pound mutt named Toto.
As a 14-year-old working in the Greensboro, Penn. mine, he picked up the habit of chewing pipe tobacco from his father, an immigrant from Czechoslovakia. After 70 years of chewing tobacco, any enforced abstinence from Five Brothers—his favorite brand—made him uncharacteristically nasty, a "bear," according to Zehner. The absence of his "best buddy" Toto was also painful for him. The white-haired, Maltese-poodle mix spent hours next to him on a bed filled with dog toys: a rubber carrot, a faded Santa Claus, a pink squeaky dog, and rawhide chews. "The dog was so important to him," Zehner recalls. "Every time when I’d go out or to the store to get anything, he’d say, ‘When you go to town, buy my dog a toy.’"
When Krupinsky spent a couple months in a rehabilitation center after a knee operation in 1991, he became severely depressed, refusing to talk or respond to Zehner or other family members. "It was pitiful," says Zehner."I think one of his biggest fears every time he’d go to the hospital was that he would not come home."
No small part of John Krupinsky’s fear: Neither Toto nor chewing pipe tobacco is welcome in hospitals.
A Hospital at Home
Though he was strong and "worked like a horse" his whole life, John Krupinsky’s last few years were spent in bed. His bad knees had made it impossible to walk so he had to give up his morning routine of loading a coat pocket with dog biscuits and shuffling up the alley to feed the neighbors’ dogs. He’d still watch his favorite television show ("The Price is Right") and his favorite movie ("All Dogs Go to Heaven"), but his heart and lung problems left him weak and short of breath. The assorted ailments required frequent trips to the Bayview Medical Center.
For Rose Zehner, overcoming her father’s resistance to hospitals, taking him from his tobacco and Toto, and physically getting him out of her home was becoming more and more difficult. On October 8, 1996, her father’s congestive heart failure again required medical attention. This time, instead of standard hospitalization, he was "admitted" to a new program initially called Home Hospital. The program was supported by a grant from The John A. Hartford Foundation of New York. Currently the program, now called Project at Home, is in a study phase at hospitals in three health systems around the country: Fallon Healthcare System in Worcester, MA.; the “At Home” Partnership in Buffalo, NY; and the Department of Veterans Affairs Medical Center, Portland, OR.
Mr. Krupkinsky was its first patient. The concept, which seeks to treat elderly patients suffering from specific illnesses in their homes rather than at a hospital, was started at Hopkins. "I thought it was a wonderful theory," says Zehner, who cared for her father at home in his last 11 years. "There’s nothing better than home care because patients are far more comfortable there than in the hospital."
Few gerontologists would argue with Zehner. Although the hospital is looked to as the "gold standard" of health care, it also carries a slew of risks for the elderly who use it more frequently than any other age group, according to John R. Burton, a geriatrician and Chief of the Johns Hopkins School of Medicine’s Division of Geriatric Medicine and Gerontology. The elderly often become disoriented in hospitals, making them more subject to falls. Dehydration may exacerbate any dementia already present and cause delirium. In addition, old people are particularly susceptible to iatrogenic illness (sickness or infection picked up in the hospital). An old medical joke has special relevancy for the aged: The hospital is a terrible place to be if you’re sick.
While most caregivers instinctually rush sick seniors to the hospital for treatment, Project at Home presents a viable, less expensive alternative. "We think we can do it safely in a more comfortable setting," Burton says. He leads a group of physicians, nurses, and researchers that teamed up in 1994 to provide an option for seniors facing acute hospital care. Of the top 10 most common diseases that lead to hospital admission, the team selected the four best suited for home treatment: pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and cellulitis. They then developed a set of protocols to further identify patients with these diseases, ensuring only those best suited to Project at Home would be admitted. Patients who are living alone are eligible for the program, though in order to make physician visits feasible, patients had to live within a defined area near the participating hospital. In general, about a third of patients with the selected diseases qualify for Project at Home.
In the Project at Home scenario, the patient is "admitted" to the hospital by a doctor, but treated at home. In most cases, the patient receives round-the- clock supervision from a nurse for an initial period and appropriately reduced supervision thereafter. The doctor visits patients daily. Without leaving their own beds, patients can receive X rays, electrocardiograms, oxygen, IVs, medications, and other services normally associated with hospital care. The small pilot study, involving 17 patients, had encouraging results: treatment could be safe, effective, satisfying to patients and their family members and charges were 60 percent what they would have been for normal acute hospitalization, according to a 1999 Journal of the American Geriatrics Society article published by the team.
Harriet Gordon, an 82-year-old who lives in a retirement community northeast of Baltimore, participated in that study as a patient three years ago. After she fainted in her kitchen and was diagnosed with pneumonia, she was offered a chance to be admitted into Project at Home. "I said I’d much rather stay home, of course," says Gordon. "I didn’t have any terrible experiences at hospitals but I knew you always had to have a roommate and sometimes that they’re not compatible, and the food is not really good." Following a week of visits by the doctor and nurses, she was "released" from the home hospital, though the team continued to check up on her afterwards. As with a standard hospitalization, the length of time in the home hospital program depends on the severity of the patient’s illness. Gordon has recovered from the pneumonia and was soon able to return to her bridge games and volunteering at the retirement center’s library. Asked what advice she would give to others who may have the option of being treated at home or in the hospital, she laughs and says, "Home."
While Gordon’s positive experience was mirrored by most of the other participants, more studies must be done before the world of elderly hospitalization will be revolutionized. A national trial in three cities (Worcester, MA, Buffalo, NY, and Portland, OR) is under way. It involves a Department of Veterans Affairs Medical Center, managed care groups, an academic medical center, and a school of public health. In 2001, the team began a control group study, following patients admitted to the hospital in the traditional manner. In 2002, patients from the three sites will actually be admitted into the Project at Home program.
Foremost among concerns being looked at are medical results: how do clinical outcomes of hospitalized patients compare with those admitted to Project at Home, especially since these patients lack ready access to some of a traditional hospital’s acute care technology. "You might think it’s not a good idea, but I think it’s likely to be good because so many excessive procedures and tests are done in hospitals," says Burton. The proximity to technology in hospitals increases use of those resources, even when it may not be vital: Doctors are more likely to request a CAT scan, for instance, for a patient when it is just an elevator ride away. In any case, the services not provided in the home, such as MRI, endoscopy, and others, can be obtained on an outpatient basis. But medical success, safety, patient and caregiver satisfaction aren’t enough. Project at Home must also prove its financial fitness in today’s cost-driven medical environment. "We realize that it could not be more costly than a hospital or we’d be out of business," Burton says.
In carrying the banner of Project at Home, the Hopkins team has had to do battle on several fronts. They had to convince Bayview’s Institutional Review Board to be allowed to conduct the studies. "It’s very difficult to do because what we’re doing is swimming against the stream of the medical establishment, of ‘you’re acutely ill, you go to the hospital.’ That’s the way you’re trained. That’s what you’ve done in your work, but it’s not necessarily the way it ought to be," says Burton.
While it seems implausible that today’s harried doctors and nurses could have time to make “house calls,” Bruce Leff, MD, Associate Professor of Medicine with a joint appointment in the Public Health, believes that Project at Home will be more satisfying to patients and doctors. "There are many moments when you look at a person (at home) and think, if they were in the hospital they’d be delirious, screaming and pulling out IV lines. You know in your heart you’re doing the right thing," says Leff, who was one of the doctors who made house calls to patients in the Baltimore study. "I think, overall, when delivering care to frail elderly people more susceptible to potential dangers of a hospital, it’s the right thing to do."
Leff adds that there is precedent for revolutionary changes in the way hospitals work. "It’s something akin to what happened when intensive care units developed in hospitals," he says, noting that ICUs didn’t exist until after World War II. "Now, you can’t walk into any hospital in America without an ICU of some sort." If the studies prove successful, an acute Project at Home department may be an integral part of any hospital of the future, as essential as intensive care or the ER.
Project at Home is striving to find ways to maintain the best possible quality of life for the longest possible time. Ultimately, of course, even their best efforts will be blocked by a single, irrefutable reality that life comes to an end.
For John Krupinsky, it came almost three years after his home hospital experience. Rose Zehner would hear her father praying in his basement bedroom in Slovak, the language of his parents and his childhood. But she recalls that he would end each prayer in English: "He would say, ‘Oh, let the good Lord take me already.’"
In those last weeks, every time Zehner went down the basement stairs to her father’s room, he would thank her for caring for him and letting him stay at home. "He kept saying, ‘Rose Marie,’—he called me that—‘I want to thank you for taking care of me the way you did.’" Zehner recalls. "I said, ‘Dad, we’re doing the best we can.’"
Surrounded by dog toys and with his dog Toto in bed beside him, John Krupinsky died at home on Easter Sunday, 1999.