Sunday, April 4, 2010
Patient 'Dumping' Burdens Hospitals
By Michael Vitez, Inquirer Staff Writer
One in an occasional series.
See related photos taken by
Philadelphia Inquirer staff
photographer and Pulitzer-prize
winner Tom Gralish.
When the afternoon sunlight streamed in her hospital window, slashing through the venetian blinds, the shadows made Soon Ja Kim, 83, look as if she were behind bars.
In a real sense, she was.
She was admitted Dec. 23 and spent all winter in a private room at Abington Memorial Hospital. She watched the record snows outside her window and was still there for the purple crocuses of spring.
Mrs. Kim was approved for discharge Dec. 27, four days after she arrived.
But she had nowhere to go.
Her family had left her in Abington's emergency room with no intention of returning to get her. This was done not thoughtlessly, but in desperation, and with a heavy heart. There is slang in the hospital world for what the family had done: dumping.
It happens in many hospitals. One patient, for instance, just left after spending 10 years in a New Jersey hospital.
Mrs. Kim is 4-foot-8, speaks no English, and has been in America, illegally, for a decade. She has arthritic knees and can no longer stand. She needs a nursing home. But none will take her.
Because of her illegal status, she is ineligible for Medicaid, which pays the bill for two out of every three nursing-home residents. Without Medicaid, and with no means of her own, she became Abington's problem.
Covering illegal immigrants was a red-hot issue during the health-care debate. When President Obama vowed to Congress that "the reforms I'm proposing would not apply to those who are here illegally," Rep. Joe Wilson of South Carolina yelled, "You lie."
The final bill provides no remedy for Mrs. Kim.
On March 12, after 80 days, the charges – the sticker price that few pay – were $444,208.63. The true cost of her care, said Louis Incognito, Abington's reimbursement director, was $1,200 a day – $96,000, and rising.
Mrs. Kim was living in South Korea in 1990 when her daughter, Mi Cha, married an American soldier stationed there, Terry Mason of Media.
Terry and Mi Cha Mason had a child, Krystal, an American citizen at birth.
The marriage dissolved.
Mi Cha Mason decided to raise her daughter in America. Of mixed race and with a single parent, Krystal would have a better life and receive a better education in the United States, her mother and father felt.
All three generations of women arrived on the same flight in December 1999. Krystal had an American passport. Her mother, as the wife of an American soldier, had a green card, granting her legal residency. And her grandmother, Mrs. Kim, came as a visitor, with a visa.
They received help finding an apartment from Terry Mason's brother, Fred, a local police officer. Terry Mason remained in South Korea and has not responded to e-mails. Krystal said she had little to no contact with her father.
Mrs. Kim never returned to South Korea. She cared for Krystal while Mi Cha worked at Best Produce, a Korean-owned market in Media, to support the three of them.
"I was like a wife to my daughter," Mrs. Kim said.
That arrangement worked fine until last fall, when Mrs. Kim became the one who needed care day and night.
On Oct. 2, Krystal, a senior at Penncrest High School, drove her grandmother to Riddle Memorial Hospital, four miles from home.
Mrs. Kim spent a week there, came home for three days, and went back for 52 more days, until Dec. 2, when she was discharged with a promise of help at home.
Two days later, the family took Mrs. Kim to Riddle a third time, but the hospital did not admit her. She was treated as an outpatient and sent home. (Riddle's total charges for Mrs. Kim were $387,063.30.)
Mi Cha was overwhelmed.
A week before Christmas, Krystal came home from her after-school job at Body Central at the Granite Run Mall and found her own mother extremely sick.
"I saw her lying on the couch," Krystal recalled, "and she couldn't breathe, and she was coughing. I said, 'You've got to go to the hospital.' She didn't want to go because my grandmother was so sick and she was taking care of her. I said, 'I can take care of Grandma. You've got to go to the hospital.' We thought that night she'd come back home, but she never did."
Mi Cha spent three weeks in Riddle.
Krystal realized she couldn't care for her grandmother, not with high school and her job.
Members of the Korean American Association, a volunteer group at the heart of the region's Korean community, suggested that Krystal take her grandmother to Abington Memorial, 31 miles away.
They told Krystal that Abington would take good care of her grandmother. Thousands of Korean Americans live in that area of Montgomery County. An association member even came to their apartment, helped Krystal carry Mrs. Kim in her wheelchair down the six steps to exit the building, and drove them to the emergency room.
One among thousands
Of course, nobody at Abington knew any of this.
The hospital has 120,000 patients coming through the ER every year, and 40,000 patients admitted, and 500 hospital beds full every day.
"She came in with what looked like acute pain and an inability to ambulate and no one to safely care for her," said Maryteresa Mintz, the head of case management at Abington, whose team of social workers arranges timely and safe discharges.
Because it was so late and nobody at home could care for her, "we couldn't send her out in that condition," said Mintz.
The hope, she added, was that doctors would ease her pain, investigate other conditions, give her some therapy, and move her safely to a more appropriate setting, as the law requires. "That's what we would routinely do."
Indeed, that's what happened – at first.
The hospital gave Mrs. Kim a complete workup.
Her ankles, knees, abdomen, and chest were X-rayed. She received lab work and urinalysis. She had type-2 diabetes and hypertension, both treated with daily pills.
"Her weakness and ambulatory dysfunction seem to be due to extensive osteoarthritis and degenerative joint disease," one doctor wrote.
No amount of therapy would enable her to walk again on her own. A hospital couldn't really help her.
A summary note in Mrs. Kim's medical chart, dated Dec. 26, stated: "Patient to be discharged tomorrow."
But on the 26th, it became clear to case managers that this was going to be what is called a "difficult discharge." The family couldn't be reached, and because of Mrs. Kim's status, there was no chance of a nursing-home placement.
Days passed, then weeks.
"Her daughter has never taken any of my calls," Mintz said in late January. "Every letter I've sent has come back. . . . So I've been dealing with the teenage granddaughter, and she can't make decisions."
On Jan. 29, Mintz said, she had this exchange with Krystal on the phone:
"Is it your intention to leave her here?"
"Oh, no," Krystal told her.
"Well, what did you think would happen?" Mintz asked.
"We didn't know," said Krystal.
'It's my birthday?'
By Day 42, Feb. 2, Mrs. Kim had lost track of time and didn't know it was her birthday.
A hospital computer, however, flags patient birthdays and triggered the delivery of a small birthday cake with vanilla frosting and sprinkles.
Mrs. Kim had not one get-well card by her bed, no flowers or family photos on her windowsill. Her daughter and granddaughter were afraid to visit and had no way to get there.
Mrs. Kim's room in the Widener Building was at the end of a hall, across from the nurses' station.
Nurses would let her sit in her wheelchair just outside her doorway so she could watch them come and go.
On Mrs. Kim's birthday, the family of a patient in the next room, who was going home, saw the cake on her lunch tray and left Mrs. Kim a vase of flowers – hand-me-downs – as a gift.
Mrs. Kim didn't even realize this was a birthday cake, or that these flowers were a birthday gift until Sung Cho, the hospital's Korean interpreter, visiting that afternoon at a reporter's request, explained.
"Oh, it's my birthday?" she said to him in Korean. "Because I'm at hospital, I lost track of time, and I don't pay attention to dates."
Nurses and doctors could communicate with Mrs. Kim at any time through a special phone in her room, with two receivers, connected to a translator in California. The hospital also had the interpreter on staff, Cho, who could come in person for the most important or complicated conversations.
Mrs. Kim spoke in English to nurses when nature called – "peepee," she said, and "poopoo" – and the staff would respond quickly. But she felt nurses had started to ignore her weeks ago, and now barely even noticed her.
Nurses tried to give her the same attention and care they gave others. Mintz said some had become frustrated. The average length of stay is more like three days, and even with insurance, patients recovering from surgery or illness go home so quickly these days. But not Mrs. Kim.
Through the interpreter, Mrs. Kim explained how she had come to Abington.
"A lot of Korean people mention to me that this is a really good hospital. And for people without insurance, they will take care of you. . . . I don't think you guys want my money. Nobody is asking me to pay."
She talked about her daughter and became deeply upset.
"My situation is very hard," she said. "I need to get well before I go home. If I don't walk completely when I get home, then my daughter cannot work, because she must take care of me."
"If she doesn't work, then how are we going to live?"
"I'm so sad for my daughter," she added. "She's the only daughter I have. For me to look at this situation, is so hard for me."
Mrs. Kim wept.
A daughter's despair
On Day 56, Feb. 16, Mi Cha Mason sat in her Media apartment and wept with unbearable sadness.
She felt despair for her mother, trapped in the hospital, and guilt that she couldn't care for her. She felt guilt over her daughter, whom she burdens with this nightmare, and anxiety that she wouldn't be able to support her much longer.
She felt bad for the hospital, which she knew wanted her mother out.
"I think about death 99 percent of the time," she said in Korean, with Krystal translating. Mi Cha speaks English, but poorly.
She contemplated her own death, she said, and, even worse, her mother's. That would solve most of their problems. But what daughter wishes for her mother's death? The guilt made her cry harder.
"I have trouble breathing because of the stress," she said. "I just want to give up."
After Mi Cha spent three weeks at Riddle in December and January, she came home to find herself out of work. Her hours at Best Produce, where she had worked for seven years, had been cut because of the economy, and now, after being away so long, the market let her go. The owner said she would give Mi Cha her job back, but was concerned that Mi Cha was too sick and couldn't leave Mrs. Kim alone.
Mi Cha, 56, said she had been looking for a new job, but didn't have much hope. "I am old, I don't speak English very well, I'm sick, and the economy is so bad," she said as Krystal translated.
The Korean association's involvement prompted articles in the Korean-language newspaper, generating $10,000 in donations, enough to pay rent and utilities from January through April, for which Mi Cha was grateful.
When Krystal was a little girl, her mother took the test to become an American citizen – and failed. She never tried again. Passing could have prevented the current fiasco. Were Mi Cha an American, she could have petitioned to get her mother a green card, legal status, which would have entitled the elderly woman to Medicaid – and a nursing-home bed. But even if Mi Cha could pass a citizenship test, one local immigration lawyer said he was not sure the government would grant Mrs. Kim a green card, knowing she would immediately obtain Medicaid and enter a nursing home.
During the three weeks around Christmas when her mother and grandmother were hospitalized, "it was lonely and scary, and I didn't like it," Krystal said, "but I got by."
Krystal, 19 now, pretty and smart, puts up a stoic front.
"It's upsetting, but, like, what is there to do?" she said. "You just have to live with it. Life is tough, but you've got to be tougher. And at the same time I want to enjoy my teenage years. It's not like I can go back to it."
She has a boyfriend who gave her roses on Valentine's Day. So that's something. But sometimes at night, Krystal said, she breaks down and cries.
"I kind of feel like they're pressuring us, and they don't understand because they're not in my shoes," she said of Abington social workers. "Like, we understand she can't live there, but we have to think of something. And I just feel nobody is trying hard enough to try to find a nursing home."
"We tried it once, bringing her home," she added. "You have to constantly be with her. And then none of us can work. And we make no money. Nobody understands that."
No is not an option
Hospital social workers and executives understand how complex and extensive this problem can be.
"Everyone dumps in the hospital because we can't say no," said Nancy Floom, case manager at Jersey City Medical Center, which recently discharged a patient after 10 years, finally getting him citizenship, Medicaid eligibility, and a bed in a nursing home.
"This is the door that never closes," Floom said. "The standard here is everybody must be seen, evaluated, and given a safe discharge."
Case managers often have monumental tasks. What if a patient is so aggressive or threatening that no nursing home or home health agency will take him or her? Variations are endless and sometimes insurmountable.
Cases of illegal immigrants are the most vexing.
"Time and again," Floom said, housekeepers here illegally will be with one family for 20 or 30 years, "something happens to them, and they're dumped at our door."
Floom said the U.S. government, in her experience, would not send illegal immigrants in hospitals back to native countries unless they were criminals or security threats. They remain a hospital's problem.
The American Hospital Association said it didn't track cases like Mrs. Kim's, but a spokesman said she believed, based on anecdotes, that the frequency was increasing.
"In the last several years, most hospitals in the region have probably had a patient or two in this situation," said Kenneth Braithwaite, regional executive of the Delaware Valley Healthcare Council.
The new health bill passed by Congress will not solve this problem.
"We need public policy to address this," said Meg McGoldrick, chief operating officer at Abington. She said it was unfair to expect hospitals to treat everyone regardless of immigration status, then not provide them with a way to discharge patients who don't belong there.
In the last decade, one patient lived at Abington for three years, another for five.
Referring to Mrs. Kim, Mintz said: "The way she got in here was recommended by the gentleman from the Korean community. We had to correct him of this notion that this was a good idea. It took us a while to find out how this all happened. So we just don't want people encouraging patients to just leave your family member here and we'll take care of it."
Pain and frustration
By Day 83, March 15, Mrs. Kim had moved to a different floor. A stroke patient needed her old room.
That morning, she was sitting in her doorway, shouting for assistance, or at least attention.
After a few minutes, a nurse stopped and told her in English that she was going to get Mrs. Kim's nurse and put her back in bed.
Moments later, Cho, the hospital interpreter arrived, and Mrs. Kim was delighted to see him. She told him that she had nobody to talk to. She said she was uncomfortable in her chair and wanted to get back into bed, but first hoped somebody would give her a spin around the floor.
Staff members did this when they had time, but these were nurses, not activities directors.
Barbara Townsend, a clinical nurse specialist, entered the room and told the interpreter, "I think I learned how to say 'pain.'
She uttered a word in Korean: al pie o.
"That's good," Cho said.
When in pain, Mrs. Kim would say, "Ouchy ouchy."
The nurse turned to Mrs. Kim and tried to explain: "Ouchy, ouchy - al pie o."
"Perfect," said the interpreter.
"I'm trying," the nurse said.
She added: "If you could just tell her that we're trying hard to do what she wants to do. Sometimes she gets very frustrated with us. It's difficult not only for us to do what she wants, but sometimes we need her to do what we want to be done.
"I understand," said Mrs. Kim. "I'll follow instructions."
Mrs. Kim felt she needed to explain her situation to the nurse, and took advantage of the interpreter's presence.
"My granddaughter works after school at the mall. How much can she possibly make?
"A lot of teenagers these days are irresponsible and get sidetracked. But under the circumstances, my granddaughter is really straight. And good-hearted. Trying to do what she can to help. Just to see that is so hard."
Mrs. Kim cried.
The nurse bent over and gave Mrs. Kim a giant hug.
Still in the embrace, Mrs. Kim spoke in English.
Finding a way home
That week, leaders of the Korean association decided it was time Mrs. Kim went home.
How it came about depends on whom you ask.
Cindy Goldstein, Mrs. Kim's case manager since day one, said she had received a call Monday from Simon Shim, the secretary-general for the association. "He said that his office had spoken to the daughter and she's ready to take her mom home on Thursday," Goldstein said.
Shim said he had spoken with Goldstein and had been surprised to learn that Mrs. Kim no longer needed hospitalization.
"We thought she has to stay in hospital, but Cindy told us she doesn't need to be there," he said.
He also seemed to be sensitive to the perception by the hospital that members of his community had told Mrs. Kim and her family that she could stay indefinitely.
"That's not true," he said. "We're really trying to help her, but it's not easy because of her status."
Shim himself had visited Mrs. Kim in the hospital, and prompted the stories in the Korean press.
On Wednesday, St. Patrick's Day, Goldstein said she had confirmed with Shim that the family was waiting for Mrs. Kim's return Thursday. Believing everything was set, Goldstein went into Mrs. Kim's room Wednesday afternoon to deliver the news.
Mrs. Kim got upset. She did not want to be a burden.
At 9:30 a.m. Thursday, Goldstein called Mi Cha at home, and told her that her mother would arrive at noon.
"She pretended it was a surprise," Goldstein said.
Mi Cha asked Goldstein to please wait one more day.
Tomorrow would be an equally bad day, Goldstein replied. It's hard taking care of a frail older lady. But people do it all the time. You bring in your network, relatives, neighbors to step in.
Goldstein then went in to see Mrs. Kim, who was crying, and the social worker left the room in tears herself, her face ashen, and her hands fanning herself as she tried to regain composure in the hall.
"It's not right," Goldstein said. "This is so sad. So, so sad. This woman needs a nursing home, and I can't get her one."
"Breathe," said Mintz, who had walked up. "Breathe. This is not your fault."
A tearful reunion
They washed her hair and packed her up.
Once Mrs. Kim accepted that she was leaving, she seemed to calm down. A nurse who had cared for her since the first week came by, hugged her goodbye.
Abington arranged for a Korean nurse to visit the next day and again the next week. Gave Mrs. Kim meds for two weeks and prescriptions for refills. Arranged for a mobile lab to give her a blood test the next week. Hired a van to drive her home. Gave her a new walker and a couple of hospital blankets and two pairs of socks. Mintz would continue calling, trying to arrange for some community services.
What happens if her family support unravels?
"This woman knows the system," said Goldstein. "She's not going to come back here. She'll go to another hospital."
John Sprowl, who would drive the transport van, pushed Mrs. Kim's wheelchair into the elevator and down the hall toward the exit.
Mrs. Kim had arrived on a cold winter night. She hadn't been outside in 86 days. She was wheeled through the automatic door, into the spring sunlight and warmth.
She didn't seem to react to sunlight on her face or to the warm, fresh air.
Sprowl loaded her carefully into the back of his van. The last thing he tucked inside was the smiley-face balloon tied to the back of her wheelchair.
About 45 minutes later, the van pulled up at Mrs. Kim's apartment complex.
Mi Cha came running out. Tears streamed down her face. They spoke to each other excitedly, embraced as much as two people can when one of them is in a wheelchair still fastened inside a van.
By himself, Sprowl wheeled Mrs. Kim down six steps, so carefully, one at a time, into the basement to catch the elevator. This was arduous, but he was up to the task.
"I've never lost anyone," he said.
They took the elevator to the fourth floor, and Sprowl wheeled Mrs. Kim into the apartment. Mrs. Kim has always slept on the living-room floor. This is not unusual in the Korean culture. Mi Cha had spread out a pad and a soft pink comforter.
Sprowl, with Mi Cha's help, moved Mrs. Kim from wheelchair to floor. She winced and screamed, "Ouchy, ouchy," but finally came to rest on a little blanket, and he slid her, like a sled on snow, onto her bigger pink comforter. She was still in her hospital gown, which she preferred, and it had come partly open in the back. It wasn't a perfect journey, but there she sat.
Within a half hour, Krystal came home from school. She said she had heard her grandmother was coming home only an hour earlier, checking voice mail between classes. More tears. Krystal just looked at her grandmother, noticed she had lost weight, but was mostly struck by the streaks of gray in her hair. Living at home, the women had always colored it black.
A granddaughter's lament
On Monday morning, March 22, Krystal answered her cell phone crying.
"My mother got sick last night, and now she's admitted to the hospital, and I can't go to school because I have to watch my grandmother."
"I just called my uncle, and he said he would come. We'll see how that works. He's going to come tomorrow."
Fred Mason, 49, is a police officer on disability. Krystal, Mi Cha, and Mrs. Kim lived with him briefly when they arrived 10 years ago until he found them their apartment.
He said he had tried to help over the years, but had learned to stop asking questions because he never got answers.
"The Korean community pretty much keeps to themselves," he said. "Anymore, I only get calls when the s- hits the fan."
Like that morning.
Mason said many friends and relatives had told him these folks were no longer his concern, but he said, "Krystal is still my niece, and just because my brother broke up with them, they're still family."
Mason was a police officer for 22 years before a car accident more than two years ago left him with a back injury. He's still going to physical therapy, but said he would have time that week to sit with Mrs. Kim in the apartment while Krystal went to school.
He could give her food, change the Korean videos, help her lie down or sit up.
Since Mrs. Kim lives on the floor, and Fred couldn't lift her and help her to the bathroom, she wore a diaper.
"Haven't changed a diaper in years, since my own kids were small," he said.
But that Friday, he did.
"Do what you got to do," he said.
He was able to help out for a week until Mi Cha was discharged from the hospital. He could help in a crisis, he said, but this wasn't something he could do daily. He had his own family, his physical therapy, his mother to look after.
As for any solution?
"I'm completely lost," he said. "Welcome to my world."
What will become of Mi Cha and Mrs. Kim is unknown. At least Krystal has a plan. She has been accepted at nearby Cabrini College and plans to attend in the fall.
She wants to be a nurse, and an interpreter for patients like her grandmother.