Green House-ists

Bradley Flansbaum

Posted 11/06/11 on The Hospitalist Leader

The August study in The Annals of Internal Medicine assessing global costs of hospitalist care both inside the hospital, and subsequent to discharge initiated reflections within our ranks.  It was also prominent in the lay press (“Are hospital-based doctors fueling health spending?“).

I found the data credible, and the conclusions that questioned our efficiency authentic.

Conversely, the shortcomings of our collective performance are likely less attributable to the hospital-medicine model, and more consistent with its early evolution and growing pains.  Group variance and hospital setting, as well as differing levels of physician experience produced the expected results.

As I read a recent NYT piece entitled, “A Nursing Home Shrinks Until It Feels Like Home,” for an inexpressible reason, I kept hearkening back to this Annals citation.  Initially, the connection seems inapparent, but its the sum of the article’s parts that exhibit the logical link:

“There are 117 Green Houses across the United States now, part of a quiet but intriguing effort to de-institutionalize elder care. […]”

“[…] The Green House concept is the most comprehensive effort to reinvent the nursing home, experts say — including the way medical care is delivered. In traditional nursing homes, employees typically have narrowly defined jobs: Some give baths, some cook, some do laundry. It’s a system based on efficiency that tends to ignore individuals’ preferences and needs. […]”

“[…] If you have one person doing everything, they can spend more time with the residents and get to know somebody as a real person,[…]”

“ […]You’re also less locked into a rigid ‘wake, meal, bath’ schedule, and you can reorganize someone’s day based on her preferences,” he said.

If nurses’ aides aren’t feeling rushed to dress and bathe residents, the thinking goes, they’re more likely to let them perform more of these tasks themselves, fostering independence.[…]“

However, this sentence hooked me above all others:

“Perhaps more important, whether the Green House model improves care for the elderly, compared with institutional settings, is not known.”

Anecdotally, these centers cite less decubiti, more personnel interaction with residents, and higher levels of staff and patient satisfaction.  I finished the piece, and the voice inside me spoke: “what’s not to like, let a thousand flowers bloom.”  No doubt, most non-physician readers concurred; they can grasp a “green house-ist,” but a hospitalist not so much.  It is the tougher hill to climb thing.

Thus, we have a framework of care, organized around the patient with one individual in charge.  This care paradigm breaks with convention, would require a long-term care rethink (read: expensive upfront costs and an upending of the status quo participants), and on its face—despite a paucity of evidence—appears a worthwhile pursuit.

Will the new approach have some disadvantages?  Yes, but if executed correctly, and that’s the operative principle, it seems like a better mousetrap.

Got the connection now?  I am sure you do.

Bonus: What do Led Zeppelin and The Who have to do with healthcare?  This.  Calling Dr.’s Plant and Daltrey!


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