Doctors focus on providing home care

MIDDLEBURY — The newest addition to Middlebury’s health care community isn’t rolling out the latest technology or advanced batteries of tests. In fact, in the case of Partners in Palliative and Home Care — the practice launched by two Middlebury-area doctors this fall — a new approach to medicine looks remarkably old-fashioned.
Dr. Will Porter and Dr. Diana Barnard, former family care practitioners at Middlebury Family Health, are building their new practice solely on home visits. The palliative care practice concentrates on providing health care services and support to patients dealing with life-limiting illnesses or who are nearing the ends of their lives, and focusing on managing symptoms rather than curing disease.
“Part of the desire to make this switch in focus is intentionally to get back to the old-fashioned style of medicine,” said Barnard.
That “old-fashioned style” includes valuing a doctor’s time and presence and escaping the drive in modern medicine toward the next test or the next medication. It’s not a replacement for or indictment of modern medicine, Barnard and Porter explained, so much as an alternative shift in approaching a patient’s health care, particularly at the end of his or her life.
The sort of care that Porter and Barnard are interested in providing takes into account that individuals nearing the ends of their lives are faced with a transition. Patients move from aggressively treating illnesses toward accepting that death may be approaching. When that happens, the type of care a patient receives needs to change.
“This is where we see a difficulty in American medical culture,” said Porter, which he said is generally “not being sensitive to that transition.”
Though most individuals, when asked, indicate a preference for dying at home, statistically that’s not happening: Depending on where a person lives, anywhere from 20 to 50 percent of Americans die in hospitals, where they’re often aggressively treated right until the end of their lives.
Physicians, Barnard said, are sometimes so accustomed to focusing on finding a solution to a health care problem that they don’t always have the time to step back and look at the big picture.
“That transition goes unacknowledged until someone is very ill,” Porter agreed. “(Patients have) been treated aggressively until everyone throws up their hands. They’re right at the ends of their lives, and they don’t have an opportunity to step back and say, ‘Gosh, what do I want from the last part of my life, and how can I make the quality of my life better?’
“What we want to do is improve peoples’ lives, and a big part of that is changing the way that death is handled by all of us, and giving it its place in terms of importance,” he said.
The new practice operates solely on home visits, eliminating the overhead costs of an office in favor of letting the two doctors spend more time with their patients.
Barnard did some of her first home visits a few years ago. They cropped up in rare cases, if a patient was very ill or nearing the end of his or her life, but those few experiences planted the seed for considering a new direction in her career.
“I found (home visits) to be very rewarding and helpful,” she said. “I realized that there is an important place for them to happen but that doesn’t always fit into a busy family practice model.”
Porter had a similar experience. As a primary care physician, he worked with a number of patients over long periods of time. As some patients neared the end of the lives, they grew more ill and less able to come in to his office. So he managed their care through hospice nurses, and phone calls to hospice care workers as well as to the patient.
“It’s a time when one would like to be present, but I found I wasn’t able to fit it into a busy office practice,” Porter said. “I personally have the experience of being frustrated that I wasn’t able to do what I wanted to do for someone who really needed time and a visit at home.”
Home visits allow the doctors to do a number of things that they can’t accomplish in an office setting. First, the visits are typically longer — generally in the neighborhood of an hour instead of 15 minutes or so.
Home visits also allow the two physicians to see their patient in their own environment. While this typically makes patients more comfortable, it also gives the doctors information about where and how someone lives. If a bed is too high, or a home has stairs that are difficult to navigate, the physicians can take note of potential fall risks. They’re also able to see how a patient stores and takes his or her medication.
The concept of doing home visits is happening around the country in different communities, though that sort of care has been focused in more urban settings. And in Middlebury, Barnard and Porter point out that there’s already a strong network of home care professionals and agencies, including hospice nurses. The physician link was part of the equation that was missing, though.
The two doctors’ interest in the field of palliative and home care coincides with a growing need for these services.
In general, Barnard said, the Vermont population is aging. Middlebury, more specifically, is a destination for many individuals looking to retire and spend the rest of their lives in the region.
Still, the new practice, which is owned by Porter Hospital, is fighting an uphill battle in some ways. Their new take on care swims against the current when it comes to health care reimbursement.
“Right now, in medicine, we’re not reimbursed for a lot of the work we do, and certainly not reimbursed well,” Barnard said. A doctor might get paid well for ordering a CAT scan, but that sort of funding mechanism doesn’t work when a doctor is instead focused on discussing treatment options with a patient or coordinating home health care services.
Despite the fact that the pay-off isn’t immediate, their approach is forward-looking.
“Getting paid to take good care of people is where health care is headed,” Porter said, “and this is taking good care of people.”
So far, the patients would agree. Barnard recalled a recent visit to a patient who lives at home with her daughter. Both the older woman and her daughter raved to the doctor about this new service. The patient was comfortable in her own home, and her daughter — who’d previously shuttled her mother to appointments — was grateful for the assistance and support.
In that way, the doctors emphasize that end-of-life care isn’t just about tending to a patient — it’s about taking care of families during transitions that are monumental, mysterious and emotional.
No one knows that better than Porter and Barnard, who both lost their mothers in the year leading up to the foundation of their new practice. Both women died on hospice care, and those experiences strengthened the doctors’ resolve to practice this kind of medicine.
“It can be scary to face the end of your life,” Barnard said. “Having people around who can assure them this is normal, and there are things we can do to help them, is a really important service and can make a huge impact.”
Partners in Palliative and Home Care is organizing three open houses and roundtable discussions about their new practice this month. Public roundtables are slated for Nov. 11 from 6:30 to 8:30 p.m. at the Bristol Federated Church and for Nov. 18 from 6:30 to 8:30 p.m. at the Vergennes Congregational Church.
On Nov. 12 from 3 to 5 p.m. the doctors will hold a specialized open house at the Helen Porter nursing home to meet community health care providers, care home operators and private duty caregivers.

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