August 4, 2011
by Michelle Nall, MPH, ANP-BC
“I lost my glucometer about six months ago,” Ms. D, my middle-aged, diabetic patient said during our first appointment. Despite warnings that her poorly controlled diabetes was contributing to kidney and nerve damage, Ms. D was adamant about one thing: she would never be willing to take insulin. She wasn’t convinced that checking her glucose was terribly important either.
Sixty minutes later, I began to understand why.
Ms. D wasn’t just dealing with diabetes, which was certainly my major priority for the visit, she also had untreated anxiety, chronic abdominal pain for which she never returned for follow-up, a boyfriend with a drinking problem, and a drug-dealing neighbor who not only posed a safety risk, but whose all-night stream of visitors kept Ms. D from sleeping. And, mostly because she had no way to get there, Ms. D had not seen her primary care provider (PCP) in over eight months.
By the end of the visit, I had met her boyfriend and her adult son, helped coordinate follow-up care with her PCP and previous psychiatric and GI providers, discussed housing wait-lists and transportation assistance she could apply for, ordered a new glucometer, and discussed the importance of glucose control. She agreed to check her glucose at least once daily and to restart her medication.
You might ask how, in today’s fee-for-service, fifteen-minute office visit world, I was able to spend sixty minutes with this patient and learn about the myriad of issues that contributed to Ms. D’s poor health. The answer? I was in her home.
Spending the past year providing primary care in the home has been eye-opening. Meeting patients on their terms helps level the playing field in the clinician-patient relationship and provides an invaluable piece of the patient’s history – medical and otherwise. I learned on a practical level what my nurse practitioner program had prepared me for on a cerebral level: that a patient can’t focus on managing her hypertension, losing weight, or scheduling an overdue mammogram when her housing is at risk or when her abusive ex-partner has just been released from jail. I learned the value of care coordination and how infrequently it happens, only to the detriment of patient care. I learned that some simple conversations can reduce costs: “Your doctor’s office has an on-call clinician after hours and appointment times specifically set aside for urgent care issues. You don’t have to go to the ER for that.”
Ms. D eventually did begin taking daily insulin and experienced a significant improvement in her glycemic control. This almost certainly reduced the likelihood of a later hospitalization. However, this was no easy feat: she remained resistant to the idea until we had been working together for close to six months, during which time I met her for a home visit every few weeks.
The opportunity to practice within this unique model of care came through the innovative, Massachusetts-based, non-profit organization Commonwealth Care Alliance. CCA’s focus on providing high quality, cost-effective medical care to the neediest patients, who are often the most expensive, has been the topic of much recent conversation within the health policy sphere. The idea that interdisciplinary teams with a focus on care coordination and prevention of hospital and Emergency Room use be embedded in primary care practices is the basis of the Patient Centered Medical Home model that is guiding the evolution of primary care practice.
As a nurse practitioner, I have valued the opportunity to provide primary care in this unique model, and I can no longer imagine taking a history and performing a physical exam anywhere other than in a patient’s living room. One critique of primary care I’ve heard is that PCPs don’t get to ‘do’ anything. But new models of care delivery – including home visits – are allowing us to do more than we ever thought possible. I hope these models will attract students and clinicians from all disciplines to the evolving field of primary care.
Michelle Nall is a community health nurse practitioner with Commonwealth Care Alliance. She loves ballet, reading, hiking, and cooking and is always eager to learn about how clinicians can translate patient care into policy issues that promote social justice.