There are hundreds of examples where I think our model has made a real difference in the lives of our patients, but let me tell you about just one of them.  Let’s call her Susan.  She worked hard all her life, never went to college, and had to raise three girls as a single mom in Revere, a working class town about 40 miles north of Boston. Her many jobs never paid very well — the latest was as a claims adjuster for Liberty Mutual, but they did come with health benefits and she has unfortunately needed to use them.

Although when I met her she was barely 60, she had a chart the size of a phone directory. The main problem was severe, end stage, COPD. She was on chronic steroids and home oxygen and every nebulizer known to man and then some. She also had diabetes, hypertension, high cholesterol, reflux, a Pulmonary embolism, recently diagnosed squamous cell lung cancer, severe osteoporosis and several compression fractures.  She was on 27 medications, not counting ones she took as needed, and before I met her, she had spent over 3/4 of the year either in a hospital or a rehab. When she was at home, she spent most of her days going to appointments at a dozen or so specialists at 6 different institutions that she had accumulated in her inpatient stays.

Each of these took a day in itself and she got out of breath with just 2 steps, so just dressing took 45 minutes. Walking to the car took over an hour, not to mention the fact one of her daughters had to take time off work and/or get a babysitter to accompany her.  Her primary care doctor saw her once in the last year for the typical 15 minute visit, and seemed quite out of the loop and simply used the time to deal with a single most pressing issue.

Susan and her family were deeply frustrated and had no sense of overall plan, and no one to talk to, and Susan kept getting worse, had an awful quality of life, and her family had their lives on hold.  She was also costing the system hundreds of thousands of dollars a year, and her share was bankrupting not just her but her entire family, despite her awful outcomes.

Susan’s daughter had heard about our practice from a friend and asked if we could take over her primary care. The first thing I did, after getting and reading her various charts, was drive over with her health coach to her house one Sunday evening, and sit down with her and her three daughters for what turned into 3 hours, learning all about her history, probing her wishes, and making a proactive plan for managing her many conditions.

We then built a new focused team of specialists for her. We fired most of the original ones, kept a few key ones, and added one or two more. I communicated personally with each who remained about what I needed from them, and got them to agree on joint email communication to all stay on the same page.

We trimmed her medication list considerably, getting her down to 7 standing medications from 27.  Over several phone calls, visits, and more home calls by myself and our Clinical partner Kelly we spent time teaching Susan and her daughters about her conditions and her overall state of health. We all emailed often, and set up a monthly conference call with her family to discuss her situation.

By doing this we were able to clarify the goals of treatment, get Susan to accept the end stage nature of her condition, and signed her up with palliative care and hospice. Her disease of course was still awful, but she and her family felt like they were in control. Over the next year she made just one trip to the ER, and spent the rest of the time at home, including Easter, Christmas, and Thanksgiving.

Then a year after coming to see us, her disease took a turn for the worse. She and her family, along with the team we built, decided not to be aggressive, and she passed away comfortably in her own bed at home with her 3 daughters by her side.

There are those who would argue this sort of care is unrealistic and not scalable, but the economics are clear: Susan had had over 6 hospitalizations in the prior year at a cost of well over $100,000. Our time and interventions were not just incredibly cost-effective but cost-saving in comparison. And more to the point, this is exactly the sort of care we would want for ourselves or our mothers if they were ill.

I’ve decided it’s time to stop making excuses, and start building a system that can and will deliver this sort of care.  I hope you follow along our journey, and encourage others to do so as well.