I recently saw a patient of mine admitted to the hospital for the fifth time over the last six months. She is a wonderful 70 year old retired teacher who is known as a ‘frequent flyer’ to the hospital system. Her concerns are always the same; shortness of breath due to fluid buildup in her lungs and body. We remove the extra fluid and her breathing improves. The job from our end seems to be done. Or so we thought.

Similar to her previous admissions we got rid of the extra fluid, gave her medications to take back home, emphasized the need for proper diet and medication adherence and yet we feared that she may return.

Maybe I needed to spend more time with her to parse out clues that may lead me to the reason for her visits. But unfortunately patients don’t always provide all the details or may avoid information they think is unimportant.

Most of healthcare is traditionally consumed by a small percentage of the population who lie in the latter end of the age spectrum. So our lovely, charming yet fragile elders who have multiple illnesses with varying social support have to take many medications. Any small event may tip them towards a hospital visit. Invariably these events are caused by not taking medications, or taking too many, dietary non-compliance and side effects of medications. As a physician is it my job to worry about this?

Well of course it is. Doctors meticulously go over the details of management with patients. But things usually don’t work out as planned.

So what to do about it?

Behavioral change is on option; and through multiple encounters it is a powerful tool that can be used in a clinic setting. However it is relatively less potent during a short hospital stay. The key lies in understanding the social construct within which our patients (especially the elderly) live in addition to the information we’ve acquired from them. Home visits are a way this can be achieved.

Remember the time when you heard people say that ‘a doctor would come to our house, he would give out advice and medications and be part of the family’. During medical college I romanticized about the idea of sipping tea with my patients at their home while I learned from their life experiences and in turn provided ailments for their concerns. Home visits have indeed shown to decrease rates of hospitalizations and improve quality of life in the elderly. Our wiser generation should not be poked and prodded in a hospital if they can be managed at home. They should be comfortable and cared for in an environment of their choosing and be allowed to be the authors of the final chapters of their lives. So we asked our patient before she was leaving the hospital;

‘Is it ok if we come visit your place next week?’

‘What for doctor?’

‘Well I feel that we’ve created a great relationship here and I want to know you better; but also to see how well you are taking your medications, and if you are able to walk around in your house’.

Really?! Thats wonderful! I didnt know that doctors did that these days.

Her face lit up and she had a twinkle in her eye.

Our entire team visited her the next week; she had a pill box which her best friend would fill out and she told us how she took them. She moved around the house with her walker and showed us pictures of herself and family. We sat in her living room and talked about her diet. Her friend would prepare meals for her which she would heat up on the stove.

We then were taken to the kitchen where we were allowed to look through her kitchen cabinet and saw a stack of canned soup. I held a can and saw ‘18% sodium content’ in bold letters. This was our ‘aha’ moment. High salt leading to fluid buildup in her body including her lungs causing her to get short of breath. She revealed to us that that she drinks canned soup 2-3 times per week. A detail not provided when we inquired in the hospital. We explained to her the cause of her admissions; came up with a plan and left with a sense of fulfillment.

Incorporating home visits into physician work has a high return on investment as it prevents the burden of hospital costs and extra medications in addition to improving patient satisfaction. It is imperative that medical academic institutions adopt a component of home visits to highlight its re-ignite its importance in patient care.