Doris is 97 years old and has lived in the same cozy apartment in the Bronx for 38 years. Every night she takes an elevator ride to her daughter’s apartment for dinner. Three other children live within driving distance and only her oldest son lives far away. In this family give and accept are done without the words “obligation” or “burden.” Doris saved for a rainy day in old age, and like many middle class people of her generation she also saved to leave something for each of her five children. I am told she reads her financial reports weekly and is still earning from wise investment choices. Many years ago, Doris set up five separate accounts in her own name with each of her children as joint account holder because that’s what she knows about how to hand off cash after death, but before that she has a 98th birthday party in June. I am her physician so I know she has a good chance of living another 2 1/2 years which would make 100. When she did her own financial planning, she didn’t expect to live so long or ever need a paid caregiver for herself. Now, the weather has changed from a sunny investment report to a raining downward functional status with chance of thunder storms.
When I became Doris’ physician ten years ago she came to my office walking with a cane. Since then she has had only cataract surgery and no hospitalizations. Two years ago she became homebound and our doctor-patient relationship is now conducted in her living room. As is true in most cases, becoming homebound was insidious. First she stopped going on the long ride to family gatherings in New Jersey. Next, she declined her son-in-law’s car service to church because getting in and out of the car was too much. She says her legs feel weak. Sometimes she calls herself “lazy.” Each of her medical problems alone is not enough to cause her to be homebound, but all together they add up. She knows without my telling her that more health care can’t fix these problems.
In the last six months she started falling. First, it was a fall while walking to the bathroom at night and another one a month later. Now, her daughter calls about two falls in one week getting up to go to the kitchen. She has a walker, and a walk-in shower. Doris’ physical therapist says she isn’t meeting Medicare’s criteria for improvement in functional status after many months. Two weeks ago, I saw her in her living room after an emergency room visit to celebrate that it wasn’t a hip fracture. Geriatricians call it “falling” because at age 97 a fall is never a single event, rather “falling” is the beginning of a period of repeated falls. Medical success for “falling” is measured not in cure, but in reducing the number of falls or not breaking a bone.
The only remaining intervention to reduce the chance of the black cloud of a hip fracture before her 98th birthday party is round-the-clock homecare, but with investments in her name, Doris doesn’t qualify for community Medicaid homecare services. She is a middle class saver who has never had the age-appropriate combined financial planning and legal assistance to obtain Medicaid. As a geriatrician, the only consult I can call is an elder attorney who has the umbrella of knowledge on how to preserve a modest estate for her children while allowing her the benefit from the federal entitlements to home care.
Jomarie Zeleznik, MD, FACP is Clinical Assistant Professor of Medicine at Albert Einstein College of medicine. Her practice, Comprehensive Geriatric Care, is dedicated to providing accessible primary medical and palliative care in the homes of homebound elderly in the context of a committed, long-term doctor-patient-caregiver relationship. She is happy to listen and give direction to anyone who is caring for a homebound senior.
www.comprehensivegeriatriccare.org
718 561-0041
