I can still recall the lilac scent of the old lady’s perfume, the dim light in her living room due to pulled drapes and thick lampshades. Today, I would use my cellphone’s flashlight to read the paper medical record. But I’d also have a laptop, and back then cellphones weren’t yet invented. As a family medicine resident in the late 1980s we visited one patient each year at his/her home. It is still done in residencies today. One learns so much about a patient when you see them at home, gets the whole picture. Since then, I can count on two hands the home visits I’ve done. Some of those visits were on my own time. A physician rarely has the time or is paid adequately to make up for the patients not seen in clinic when out on a home visit. Instead we send home health nurses or care managers into the home to do the viewing for us. If the communication is good, that might be enough, but it’s not the same as seeing, smelling and hearing yourself.

For the last few months I’ve been doing home visits for a health plan I’ll call XYZ. The plan employees nurse practitioners and physicians to visit clients who have certain types of coverage, usually Medicare and Medicaid.  XYZ’s goal is to maximize the payment they get from these government insurers by making sure that every possible diagnosis is used. (That’s another blog post.) I have been on the receiving end of these reports and never found them terribly informative or helpful. Often I am advised to add a medication according to a guideline or do something I’ve already done and the health plan doesn’t know it. Our electronic records don’t talk to each other, or I have good reasons for not following the recommendations for that patient.

As a result, I started my first day of home visits somewhat suspect of what I would find. It was the middle of the afternoon on that chilly March day by the time I saw patient #4. His house was chilly too and the elderly man, I’ll call Mr. B, sat in front of a space heater. A bag of fast food sitting on a small table next to his recliner. He was wearing his coat.

“What’s wrong with your furnace?” I asked about ten minutes into our conversation. Mr. B was well over 90, but articulate with a sharp mind,although he was a little hard of hearing. I learned he’d been trying to get anew furnace for over a year. In that effort, he’d been in touch with a local agency to help him, but for unclear reasons it hadn’t happened. He didn’t drive anymore and one of his adult children was in and out several times a week to check on him. That’s how he’d gotten the fast food, but he also received meals-on-wheels.Someone came into clean his house and help him bathe a few hours each week, but she had been tied up with a family issue that day and hadn’t made it.

Mr. B had some heart problems and had been in the hospital and emergency room four times in the last six months. That was concerning so I asked more questions. More than one of those visits was due to food poisoning. “How did that happen?” I asked.

“I don’t have a refrigerator,” Mr. B said. “Haven’t had one since mid-summer.”

I tried to cover my shock as I counted up to nine months without a refrigerator, and more than a year without a functioning furnace.

Mr. B. was hospitalized at a facility I knew, and cared for at a clinic I knew as well. How was this missed? He had had subspecialty visits for his heart. An adult child, a home health aide, and the meals on wheels delivery person were all in and out, but no one had addressed the lack of refrigeration, or the furnace.

Truly, health care and our communities are broken.

My mind raced through the cost calculations: ED visit at least $1000, the average cost of a 3-day hospital stay $30,000, meals-on-wheels and the home aid. Mr. B’s costs were well over $100,000 in less than a year and no one had figured out that he didn’t have a refrigerator or furnace. As I left the house Mr. B had inherited from his father, and made my way down the sidewalk with concrete slabs broken by tree roots, my heart swelled with sadness and anger.

Our system was so dysfunctional that XYZ health plan had instituted home visits to get better information about the clients whose lives they were covering. Granted they were motivated by money—billing for all possible diagnoses, but in my XYZ training situations like this were mentioned.

Dr. Jeffrey Brenner in Camden, NJ, started Hot Spotting, collecting data to target the high utilizers of health care, and sending in teams to address the missing puzzle pieces that perpetuated the high utilization of health care services. Many of these cases are unaddressed basic needs (housing, food insecurity, transportation) or agencies that drop the ball or are forced to drop the ball because of patient qualifications or limitations to what can be done. For example, home visits not covered by insurance because the patient drives; insurance won’t cover alcohol treatment again; patient lost coverage because he makes $100 too much. Dr. Brenner’s efforts and successes have been copied in other communities.

I went to school to practice medicine, but over the years I’ve learned that keeping people healthy is about much more than physical and mentalhealth. Now we talk about social determinants of health and how poverty, housing instability, food insecurity,limited education, transportation and utility issues, etc. affect health. We have created tools to screen for these and have social workers available in the hospital and some clinics to help with these issues when they arise. But do we want to spend our precious health care dollars addressing housing, education and poverty. Do we want for-profit health insurers tackling these issues? XYZ decided to do so, because it was being missed.

If the dollars spent on health care were redirected in a saner way, providers and/or their teams could do home visits on high risk patients once a year, money would be saved. Less money would be spent on healthcare and we could redirect resources to better education, housing, creating better jobs, etc.

But we have a fragmentation problem in the US.

Recently David Brooks wrote an op-ed about Canada’s success at addressing poverty. In short, a group of people in a single community,a fourth of whom have lived with poverty, along with business, nonprofits and government representatives came together to study and address poverty in that community. First, they talked with people. It took time. After a year they came up with a multifaceted plan which fit that community. They implemented, learned and adapted it in a collaborative manner, made the necessary policy changes. Similar efforts occurred in other communities, but featured different solutions. The goal was to eradicate poverty, not create better poor.

What are the lessons to learn here? David’s points are time, talk to learn, and cross-community planning and collaboration—making services work for people. In the US we throw money at single issues. For starters, we don’t even have universal health care coverage. Dr. Brenner’s teams pull together resources from fragmented agencies. Health plan XYZ is doing the same, filling a hole that is not being filled by our outrageously expensive and fragmented health care system. But this is a for-profit plan so they are likely making a lot of money at the same time.

When I visited the old lady with the lilac perfume, the residency clinic’s social worker and I learned that she was sleeping on her couch and using a bucket as a toilet because she couldn’t make it up her stairs anymore. She was too proud to mention it in clinic. As I recall, the social worker arranged for a portable toilet and bed in her downstairs. The home visit allowed us to collect all the information needed to provide her the care she needed to stay in her home.

If doctors and nurses can have the flexibility to do what they are trained to do and if the excess dollars wasted on our inefficient health care system could be redirected to create education that educates,housing that is safe, and communities that are encouraged to work comprehensively and collaboratively to identify and solve their unique barriers which keep citizens sick and poor it would be a better US.