Health Cuts Hitting Home Visiting Nurses See Crisis In Caring
The rooms are mazes of tightly made beds, sleek walkers, oxygen tanks and television sets. The people inside wear slippers and lug leashes of oxygen tubes.
Janice Trotter, a registered nurse, is at home here.
She asks about appetite and breathing, listens to lungs and hearts, squeezes out blood pressure readings, dresses wounds and teaches diabetics to give their own insulin shots.
“Every day is different,” said Trotter, who drives her wood-paneled Jeep Grand Wagoneer from home to home. “You see all different types of situations, all different types of people.”
Trotter, 41, has worked for the Spokane Visiting Nurse Association since 1988. Like most of health care, the VNA is being squeezed by cost-cutting measures and a growing population of older, sicker patients.
But a big target is being painted on the home-health industry, threatening coverage for some patients cared for by nurses like Trotter.
Amid fraud allegations and pressures to balance the budget, President Clinton has agreed to a package of proposals that aims to cut home-health costs nationwide.
One proposal would tighten the definition of “homebound” to narrow patient eligibility. Another would require people on Medicare to start paying premiums and deductibles for home health care.
There are plenty of other ideas where those came from.
“The home care industry is under great attack,” said Sheila Masteller, chief executive officer for the Spokane VNA. “I worry we’re not working on a continuum of care. … I worry because most people haven’t needed home care yet.”
Homebound patients are dependent on nurses like Trotter. Without her care, they could end up back in the hospital or worse.
Home-health nurses often are highly trained, yet make less money than hospital nurses. Agencies try to balance shrinking budgets with the need to pay for quality help. That leads to tense labor negotiations, like those between the VNA management and nurses last week, when a threatened strike was narrowly averted.
Trotter’s patients didn’t ask much about the labor dispute. Their caregivers, the family members wringing hands in hallways and laughing nervously, were the ones asking round-about questions, wishing Trotter luck as they wondered what they’d do without her.
“I can see both sides,” said Fred Seiller, who cares for his 74-year-old wife. “The girls - they’re wonderful. They need the money. If it were me, I’d be paying them $50 an hour.”
Trotter usually sees about six patients a day and has about 20 regular patients. Somewhere along the way - in her car, in the park, in a coffee shop - she’ll fit in a couple of hours of paperwork.
This day starts with Pearl Mansir, a 95-year-old woman in and out of the hospital with congestive heart failure. She’s pestered by nightmares about firefighters and paramedics in her home. She tries to make her own breakfast.
“She’s a pretty spry old gal,” said Gayden Mansir, her 63-year-old son, himself in pajama bottoms and slippers. “Awful independent. That’s where we have problems with her.”
He’s living with a broken back and needs both knees replaced. His wife has cancer. He doesn’t want his mother in a nursing home, where she is convinced she will die.
On this day, Pearl Mansir is doing well, but even that is relative. The boil on her back looks good. Her weight still hovers above 200, but her ankles aren’t holding fluid. Her heart sounds strong, but her blood pressure’s a little high.
Trotter pulls up the back of Mansir’s flowered shirt and listens to her lungs.
“Sounds good,” Trotter said.
“Uh huh,” Mansir replied, after a moment. “Good for another 10,000 miles.”
She is one of about 650 patients being cared for by the VNA, the largest home-health agency in Spokane. The patient and visit numbers leveled off in 1995, after quadrupling since the early 1980s.
Since then, the numbers have even dropped, from 127,000 visits in 1995 to a projected 85,000 visits this year. The number of staff - from home-health aides to therapists to nurses - also has decreased.
Pressure on the entire health care system to reduce costs has trickled down to home health, Masteller said. Providers are more reluctant to pay for unskilled care, like the VNA home-health aides who help with personal hygiene and baths.
Many VNA patients are elderly. But some are young, low-income pregnant women in the state’s First Steps program, some are high-risk pregnant women required to stay in their beds, and others just need temporary help after leaving the hospital.
Like other home-health nurses, Trotter is providing care that used to be available only in hospitals. Sicker patients are discharged more quickly, leaving follow-up at home, in small intensive-care units built in bedrooms and living rooms.
John Nelson, 79, is the first known patient in the area to receive heart muscle medication through a pump at home. The medicine helps strengthens his heart.
He is a cowboy with expressive eyebrows. In his home, cowbells hang in the corner near a set of longhorns and pictures of wranglers.
Trotter changes the pump battery, the medicine bag and the tubing, which leads to a blood vessel near Nelson’s heart. She reprograms the pump. A nurse visits Nelson every 48 hours.
Orders hang by magnets on his refrigerator, telling the paramedics that he doesn’t want to be resuscitated. These are pinned next to a card featuring the diary of a cow.
“He doesn’t want any CPR,” said Edith Nelson, his wife. “He wants no machines. He wants to go natural.”
The Nelsons, most likely, will rely on a nurse until then.
Other patients, like Shirley Piraino, eventually will be weaned off a visiting nurse.
Trotter tries to adjust Piraino’s insulin to get her blood sugar correct. Piraino, 74, also is learning to fill her own insulin shots.
When her blood sugar levels are OK and she knows what she’s doing, Trotter won’t come to her adult family home anymore.
But Piraino can’t hit the level right, her hands shaking like a cold engine. She forgets to pull in air before the insulin. She forgets to pull off a needle cover. She sucks in an air bubble.
Still, one by one, Piraino fills seven syringes. Trotter will come back, to work with her again. Her blood sugar is still off.
“We’re still too high,” Trotter said.
“I just can’t seem to win, can I?” Piraino replied.
Trotter’s patients and caregivers know the pressures on health care. They grouse about the warehousing of the elderly, about a society that makes people live longer but doesn’t know what to do with them.
Nancy Seiller reads her newspaper in bed and listens to big band tunes on her radio. She looks a study in health, with rosy cheeks and lips, crinkly blue eyes and white hair. She’s visited monthly to have her catheter changed. She can walk maybe a few steps.
She and her husband, Fred, tease back and forth, married 49 years, a long time to put up with each other. Nancy Seiller can’t hear the beeps that signal her thermometer is ready. Trotter asks about her hearing.
“I have problems here, sticking beans up my ears, up my nose,” Nancy Seiller joked.
“Silly girl,” her husband said.
“Thanks for calling me a girl,” she replied.
He stands in the hallway, pointing at pictures of their only son, who died four years ago after a fall. A good boy, he said, and tears make a brief appearance in his eyes.
The two are alone in Spokane.
“Without the VNA, it would be terribly difficult,” he said. “You’d have to put her in a home.”
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