The major medical problemof our time is long-term illness.
This is a reporton one hospital's successful experiment
in the treatment of chronic disease.
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This patient has heart disease.
He has had it for a long time.
He can expectto have it for the rest of his life.
He has been in and out of hospitals.
You see him now in his own home,and it is in his home that he receives
the full medicaland social services required.
Every patient you will seein this film has a chronic disease.
Each has had a long periodof hospitalization.
Each is now back in his ownhome with his family.
Each obtains all the treatmenthe needs at home.
These patientshave different chronic diseases,
heart cancer, arthritis, asthma.
There are hardly any chronic diseaseswhich cannot be treated in the home,
neurological disorders,diabetes and its implications,
selected cases of tuberculosis,nephritis, and so on.
These patients are part of a homecare program which permits
the patient to remainat home and still obtain
the best in hospital services.
This hospital has long concerned itselfwith the treatment of chronic disease,
and some years ago it beganan experiment in home care.
A pioneer in that experimentis the hospital director,
Dr. Martin Cherkasky,
who explains to a medical audiencehome care's philosophy and operation.
Good morning.
Today I want to talk withyou a little bit about home care.
For the acutely sick patient,
a short hospital stay is somethingthat he can take with equanimity,
but with a chronically sick patient,
since he's going to be sickfor a very long time,
to keep him in an institutionis not in his best interest
because as we probably all realize,
an institution is not the normal habitatfor human beings.
Where the patient no longer requires
the very specialized andexpensive and extensive
facilities of the hospital,then but he is much better off in his home
where he receives the kind of warmth
and affection and attention that members
of the family can give to a patient.
However, for home care to be suitable,
there has to be a careful selection,both of the patient and of the home.
The crux of a home care is the team,the doctor,
the nurse, and the social worker.
First of all, the doctor seesthe patient on a hospital ward
after he's completedhis period of hospitalization.
During that time when he's receivedoperative treatment or x-ray therapy,
the other thingsthat can only be given in the hospital,
and the doctor determineswhether his medical needs
are such as can adequatelybe met in the home.
By the way, as a doctor myself,
I used to thinkthis was the most important part
of the evaluation, but frankly,we have found that even very sick
people can be taken care of in the home,provided the second part
of the evaluation turns out adequately,
and that is the evaluationby the social worker.
To determine whether a patientis suitable for home care,
the social worker has to go in, work withthe family to find out how do they feel
about the returnof this patient to the home.
It's not automatic that every family wants
a patient back or can even takea patient back because after all,
taking a seriously sick patient
into the home is nothingto be taken very lightly.
We determine whether the familyand the patient have the kinds of bonds
between them which will enablethe patient to get that kind of warm,
tender loving care that a patientwith long-term illness requires.
The third fundamental member of the team,
the public health nurse,she has a dual responsibility.
First, she provides directbedside care for the patient,
possibly more important.
She teaches members of the familysimple nursing techniques
which they will require to meetthe needs of the patient in the home.
We have found that mothers and wives
and husbands and sisterscan be taught simple
nursing techniques like how to give
a bed bath and how to give a hypodermic,
and they become superior nurses
in the care of that patientbecause not only do they have technique,
but they have warmthand feeling for the patient.
Once we have determined that the patientis medically suitable
and socially suitable for home care,
we then return them to the home confident
that with the kind of medical program
we can provide for the patientand the kind of attention
and warmth he can receive in the home,that under these circumstances,
the home is not as good as the hospital,
for this patient it is muchbetter than the hospital.
The treatment of some illnesses
is notablymore successful in a home setting.
For this asthmatic patient,
home care proved muchbetter than the hospital,
largely because ofthe patient's emotional attitude.
Medical treatment remained the same,but soon after her return home,
her severe asthma virtually disappeared.
What do you think of the possibilitythat when you are frightened or upset,
that this is likely to give you asthmaor to bring out the asthma?
Well, still doctor now,I get frightened yet now.
For instance,unexpectedly if the bell would ring loud,
I get a horrible fright.
I don't know why,
but I don't get the asthma attacknot since I've been using this drug.
Yes. Do you thinkthat you are as frightened now
or as upset now or as nervous now
as you were when you first came home?
Oh, heavens, no.
Look at the weight I put on.
I could do my work now.
I don't say I don't get tired at times.
I have to take a little rest.
In other words, you're feelinga good deal more comfortable
-about yourself, right?-Oh, yes. Surely.
-About your strength?-About everything.
-About everything.-About life in general.
I was so discouraged, so disgusted.
I was sick three long weary years,and before that,
I never had a sick day.
That is never a day that I could sayI was very ill or any, never.
Not even a cold in six years.
This is medicallyan interesting situation.
Here we have the case of a womanwho in her last hospitalization,
spent five months with intractable asthma
on a wardsof one of our very best hospitals.
The question that arises is,
why is it that she's so muchbetter at home on home care?
This is not a situationthat we have observed for the first time.
We have seen this with other patients.
Our speculations and present conceptions
about it revolve about the ideathat many of these patients
are quite anxious whilethey're in the hospital
and when they are at home,they feels sufficiently more secure,
sufficiently more relaxed,
so that to the extentthat their diminished anxiety
helps them in dealing with their disease,
to that extent, they do better at home.
In the care of the chronically sick,
occupational therapyis extremely important.
Therapy helps minimizethe disabling effects of the disease.
It helps the patient develop her physicaland mental capacities to the maximum,
and the best place for this rehabilitation
is in the home with her family,in this case, her sisters.
The therapist is sentfrom the hospital and the patient gets
not only the feeling of medical recovery,but more important,
this gives her the confidencethat she may conquer
the depression associatedwith chronic disease.
This patient has greatly improvedemotionally since her return home.
When you're depressed,it seems that every--
You seem like you're all aloneno matter what.
You just feelthat there's nothing to live for.
You just feel that you're through,
that no one can helpyou and you're not happy.
You're seem that you're brood and brood,
you just think and pity yourself.
You just feel like, I cried and criedand just thought that I'd never,
never come out of it,but then I sort of got used to it
and with the kinds of peopleand everyone talking to me and being home
and not lying in a hospital helped a lot.
The environment at homeand you're happier and knowing
that they can come rightinto your home and help you,
you don't feel lost,and all that encouraged me an awful lot
and really put me on my feet.
Heart disease ranks firstas a cause of death and disability.
Among the illnesseswhich lend themselves best
to home care are the different formsof heart disease.
By caring for a properlyselected heart patient in the home,
not only can he remainin familiar surroundings,
but many readmissionsto the hospital are avoided
and in some casesbecome totally unnecessary.
This 66 year old patientwith a history of heart disease
had four long hospitalizations
before he went on homecare and none since.
This patient is also able
to have physical therapytreatments in his own home.
He considers he has madegreater progress on home care.
I tell himit was a 100% better than the hospital
because I think they giveyou all the care in the world.
Everything you want you get here.
Anything.
I know I didn't feel good [?] and my wife,she called
Dr. [?] so he come rightover and he give me a needle.
I could hardly breathe,so he gave me a little of extra medicine
and I felt better right away.
You don't have to wait.
They give you the best of care, the best.
I'm satisfied.
Ranking second in its tollonly to heart disease
is the most dreadedof all chronic illnesses, cancer.
Before home care,many victims of cancer had to spend
long and repeated periods in the hospital.
Many of their needs, however,can be met at home,
as for example,the need for blood if anemia occurs.
Montefiore's experience withmore than 400 cancer patients
shows that when properly selected,
they can be successfullycared for at home.
At the same time, maintainingthe highest standards in cancer treatment.
Now, it is important to recognizethat home care
does not answer all the problemsof the chronically sick.
Nevertheless,the hospital estimates on the basis
of its experiencethat 20% to 25% of patients
with chronic diseasewho are presently hospitalized,
as these patients are,could well go on home care.
Not only to patients who go on homecare
remain partof the hospital's responsibility,
they actually derive special benefits
for the doctor becomestheir counselor and friend.
Your pressure is fine, Miriam.
I think it'd be a very good ideato get out of the house for a change.
You've been homebound for a long,long time.
-A long time.-Before that it was the hospital.
I think it's time to resumein more normal life.
-I'm trying to--.-Get out of doors,
see your neighbors outside,walk around the corner, go to the movies.
I think there's a churchnot far from here,
-isn't there?-That's right.
I want you to take a bus upto the church or even a taxi cab.
A cab.
We could arrange for that.
All right, doc. I'm willing.
You can't go on with the ideaof being permanently homebound
or as a sick person,because you are better now.
-I know I am.-I know it's been a good many years but
-[crosstalk]-Well, fine.
Well, I thinkthat that's a thing for you to do.
Yes.
One of the main reasonsfor the success of home care
has been the weekly staffmeetings of the homecare teams.
Since the experiment began,
almost 1000 patientshave gone on the program.
For most of them, the program has worked.
Here at these meetings, doctors, nurses,
and social workers exchange information
and continuea constant reevaluation of the patient,
his illness, and his family situation.
It is here that a doctor will suggest
the possibility of transferringone of his hospital patients to home care.
The team discusses for Freddie M.,
a young patient with rheumatoid arthritis.
His doctor feels that Freddiecould improve at home.
On the door of Freddie's bedroom,a reminder of a happy childhood.
As far as his family remembered,Freddie had always been a healthy baby.
There had been no signsof chronic illness in childhood.
Then in the last four years,
rheumatoid arthritis had attackedall the joints in his body,
he could no longer walk.
Freddie was delightedat the doctor's proposal
that he go on home care.
Before he went home,the social worker talked with his mother.
There are other problems,because despite all the help we can give,
there's a great dealthat you will have to do for Freddie.
[crosstalk] 24 hours a day.
Well, for instance,it's difficult for Freddie
to get in and out of bed.
Freddie is a big boy, he's heavy,
it may be difficult for you to movehim in and out.
Do you think I'll be able to do it?
I think you will.
You may have to have some helpfrom your husband,
but between the two of you, you will.
We hope that in the future,not too far future,
that Freddiewill be able to do more for himself.
Of course, then things
will be a little easier,but in the beginning,
it means a new wayfor you to live together,
which you haven't hadnow for quite some time.
Yes,we'll be very happy to have Freddie home.
I know you will.
You will need a great dealof patience and fortitude to cope
with some of the problemswhich will present themselves.
For instance, you cannot expectthat any illness will proceed getting
better and better and better all the time.
Sometimes there will be timeswhen Freddie will be uncomfortable,
he will be in pain.
While you can get a doctor to help,at the same time you will be the one
that will have to witnessthe pain and bear it.
The social worker reportedback to the home care team
and the decision was madeto send Freddie home.
The hospital deliverthe bed and the wheelchair.
Hospital serviceswould be at Freddie's call 24 hours a day,
and medicines he neededwould be made available by the hospital.
Freddie went homein a chartered ambulance.
He and his family were securein the knowledge that he could always
come back if he required furtherspecialized hospital services.
Freddie has spenttwo and a half of the last four years
in various hospitals.
Like most chronic diseases,Freddie's illness had developed slowly.
It was difficult to detect,hard to cure, costly to treat.
Freddie was on his way home.
When he went home, the hospitaland the home care team went with him.
Freddie would you like to wash your face?
Good.
When we talked a little earlier,we had planned
that Freddie would takehis bath early in the morning,
and he would wash his faceand his arms and as much
as he could,and that would give an opportunity
to develop the muscles in his arms,
it would give him the exercisesthat the doctor wants him to have.
That way, he will be able to help you
to a degree in getting him out of bed.
Freddie, that's all right?
Yes, you want to rinse that out, please?
Yes, sure.
How's your appetitesince you've been home?
Oh, it's been muchbetter since I've come home.
-You're eating just about everything?-Oh, yes.
Food in the hospital was okay,but nobody can cook like my mother.
Oh, I bet she givesyou all the things you'd like to eat.
-Oh, yes.-Last night, I had a real big fix cake.
I haven't had that a long time.
Well, I'm sure your motheris happy to see that you enjoy your food.
I think so. I've been gaininga little weight, I think.
Well, you look muchbetter than you did the other day.
When we think of sick peoplewho need extensive services,
we almost always think of hospitals,and yet,
almost all of the serviceswhich the patient requires
and be effectivelybrought to him in his home.
This is especially true the experience
and ingenuityof our visiting nurse services.
There are very few nursing problemsthat cannot be solved in the home.
These exercises, for example,
have greatly increased motionin Freddie's shoulder joints.
The physical therapistvisits on a regular schedule.
Physical therapy always bringsto mind the very extensive facilities
found in great modern hospitals,but this does not in any way preclude
the effective useof these skills in the home.
Now, bend your leg, Freddie.
Pick them up again, pick them up again.
Not only can the physical therapistbring to the patient's skills,
which will help him recoverthe use of his limbs and muscles,
but the physical circumstances
and the atmosphere of the home can be used
as positive weapons in furthering
the activities of the physical therapist.
For instance, it is one thingto be taught to get out of bed
in a hospitalbut it is quite another to be taught
to get out of bed at home,
where this will help the patientto join his family at the dinner table
or watch television or chat with friends
or study with his high school teacher.
Now, Freddie, exactly what do you wantto find out in this problem?
A high school teacher visits regularly.
A college will admit Fridayonce he's able to get in and out
of his wheelchair under his own power.
Everything I wanted to tellyou it's just flew right out of my mind.
In moments of leisure,there's always television,
but from time to time,the emotional impact of chronic disease.
Your illness will be withyou for a long time
and you have doubts and fears.
Sometimes the only medicineat this stage is inner strength,
patience, and courage. [crosstalk]
Oh let's see what else we got.
Home care means you can inviteold friends to your own home.
This isn't medicine but sometimesit's better than medicine.
This is the world Freddieintends to get back to permanently.
One, two, three.
[singing] Wait till the sun shines,Nellie,
When the clouds go drifting by,
We will be happy, Nellie, Don't you cry.
Down Lover's Lane we'll wander,Sweethearts you and I.
If you'll wait till the sun shines,Nellie,
Bye and bye.
This is station TRN,
your Tape Recording Network,bringing you variety.
Nothing else, just playing variety.
Freddie has always been interestedin matters of electronic.
The occupational therapist has helpedhim round up some radio equipment.
Her reward is a home brewedcommercial by Freddie and company.
[singing]
Jack is the best for you.
Bubble, bubble, bubble.
Lately, Freddie has been able to getout of the house for some fresh air.
Sometimes it's a trip to the local icecream parlor with friends,
on weekends to drive outto the countryside with his father.
There was a time not too far back
when Freddie could not movefrom head to toe.
There was a time when his weighthad declined disastrously.
He remembers the unbearable pain
and his near addictionto narcotics to ease that pain.
There was a time when he didn't careabout living anymore,
and then there had to be psychiatrictreatment
in the hospital to bring himout of his deep depression.
Since he came home,there's been a vast improvement.
He feels better, he thinks better,he certainly eats better.
He even takes batting practice,
and his home care doctor visits
regularly to make surethere'll be no backsliding.
Do your arms, do your wrists hurt at all?
No, it's quite a bit better
than it was last week.
-That hurt?-No.
Turn them over.
Squeeze my hand.
Tight. Attaboy.
Now how are you feeling?
I've been feeling pretty good.
I feel I've been comingalong with the exercise quite well.
-You're taking what?-25 milligrams of Meticorten?
-That's right.-How about aspirin, codeine?
-Well, I think I can cut down on it.-Now that I've been having less pain,
I think I can cut down on the Meticorten.
I have cut down on the aspirinAPC already.
I think I should be able to cutdown on it.
I've been feeling quite a bit better.
How is the crutch walking coming?
Well, I haven't been doing that much.
Mr. Harvey has been doingmore exercise in the bed with my feet.
I haven't had the time.
As soon as they get a little stronger,we'll get right back to that.
I see. Because we have to keep after that,Freddie.
That's the most important thing.You've got to get up.
You've got to walk every day.
No ifs, ands, or buts about it.
If we let you slide, we'll be back
where we were six monthsago in the hospital,
and we don't want to let that happen.
Now, the most important thingis straightening your legs,
getting up on the crutches, and walking,even if it causes a little pain.
We're not interested in that.
We don't want you to be uncomfortable,
but you'll have a little pain,but you've got to walk.
That's the most important thing.
Freddie hopes to be walkingwith canes within the year.
This patient is also learningto walk again.
She is on home carefollowing extensive surgery on her hip.
To make matters more difficult,she also has Parkinson's disease.
There was a timewhen she was completely bedridden,
and as she says,already in the valley of shadows.
Her improvement has been remarkable.
One reason is her tremendousspirit of resistance against her illness.
Another reason is because
she's in familiar surroundings again,
the place she loves, her home and friends.
She has two immediate goals,to teach singing once more
and to walk down the 30 steps that leadfrom her apartment to the street.
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Touch my nose.
Karen, again.
I did it.
Once more.
I did it.
I have been toldbefore I came to the hospital,
I had been told that they didn't thinkthat I would make it,
but actually I fooled them,
or home care rather fooled thembecause there was constant vigilance.
Well, I mean, I don't want to sayanything against the hospital
because they were very nice to meat the hospital,
but the difference is so enormous,you see.
You feel you get personal careif it was the method as a person,
not just as a bed, so and so.
It means so much to the sick person.
I don't know, it's nice.
You wake up and you findthat you're in familiar surroundings,
and you get all this care coming to you.
You don't have to go after it,you feel like a queen.
It's so nice, you're in your own homeand everybody has a warmth.
Oh, they're wonderful.
They're here now even, for instance,
to help me get along the dreadlonely hours because there are hours
when you have a little too muchtime to think.
They have made me take up painting,for instance.
I'm not in the painting business,it's not Rembrandt exactly,
but really, they have wonderful teachers.
Everything,you think that it's all done for--
You don't feel that it is charity,you see.
You feelas if you're really a human being,
a person that is caredfor in the best possible care.
In summary, home care is not a panacea,
it doesn't meet all the problemsof the chronically sick.
Hospitals are still very, very important.
Of considerable significanceis the fact that home care
costs about one quarterof the cost of a hospital day.
Economically, it is a feasible plan,
as well as being feasible
in the sense of the valuesthat it gives to the patient, the family,
the hospital,and the community as a whole.
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