New England Programs I: Full Circle America

In September I did another holiday-cum-healthcare-research road trip, this time to those northeastern US states referred to as New England: Massachusetts, Rhode Island, New Hampshire, Maine, Vermont. I was privileged to visit and meet with the leaders of two programs there designed to keep frail elderly people at home, out of nursing homes, and out of the hospital: Dr. Chip Teel of Full Circle America on the coast of Maine ( http://www.fullcircleamerica.com/ ), and Dr. Dennis McCullough, founder of Slow Medicine at Dartmouth University in New Hampshire (details to come in my next post). I felt more than ever that we are on the right track in Vancouver after talking to both of these brilliant innovative guys.

Chip Teel comes across as a high-octane entrepreneur and elder-care visionary. Our first day there, Robin and I had dinner with Chip and his wife Carol at a down-to-earth local pub off the main street of charming Damariscotta, the small Maine town where they live and he practices. The next morning Chip and I sat in his office and discussed his program, he presenting me with a copy of his book Alone and Invisible No More and showing me the system he has in place and hopes to introduce elsewhere, and I peppering him with as many variably relevant questions as I could get in edgewise.

Here’s what I found. Dr. Teel’s vision for home care for frail elderly is based in widely-experienced and genuinely-felt common sense. I was delighted that we agree on many things, confirming my impression from visiting a program in Manhattan in 2010 that our problems and some potential solutions span national borders and health-care systems. The first question Chip asks a new frail elderly patient is, “How do you want to live the rest of your life?” The second, “What can you and your family do for other people in the community?” These open the doors on two fundamentals of his practice: every elderly person is entitled to decide for themselves, and things work best when people help people. He believes in “the dignity of risk”, which means that when you take away someone’s right to live at risk (closely connected to their right to living their lives the way they want to) you dehumanize them, treat them like a commodity, and un-dignify them.

(I can’t avoid mentioning the linguistic entropy that seems relentlessly to destroy constructs like “dignity”, “living at risk”, and also “evidence”, “patient-centeredness”, and now most recently “primary care”. I find the consequence of creating meaninglessness where previously there were critically important ideas terrifying. I’ll try to do a post on this…).

My next lesson from Chip Teel was economic. An American down to his sneakers, he understands the significance of money in health care the way I’m afraid few Canadians do. My own brief foray into the economic impossibility of high-quality interdisciplinary home care of frailty involved a proposal I made to a private-enterprise organization here in Vancouver which was eventually rejected because the dollar numbers didn’t add up. The truth is without new money you have to somehow save money to make frailty-at-home care sensible. Dr. Teel’s answers: first, involve the community. Volunteers in other words. Second, use smart technology.

His presentations, book, and other information about the Full Circle America contain all sorts of examples of next-door neighbors, similar-interest new friends, family members, and kindly souls pitching in to do (usually for free) things that without their help would cost money. Transportation to and from appointments, getting an elderly lady to a nursing home to do a piano concert, teenagers popping in at noon to make sure the old guy up the street has had his breakfast, sort of thing. I’ve heard the criticism from, say, Canada Health Act fundamentalists that a program which relies on volunteers isn’t sustainable or politically correct. And more credibly for me I also hear the one summarized in the comment, “Spoken like someone from a small town.” It’s much harder to develop the kind of networks that work in Damariscotta (pop. just over 2000) than in most neighborhoods in Vancouver with its million and a half people, let alone Toronto or Los Angeles. But that doesn’t mean it can’t be done in some attenuated or different way. The biggest city in the world is made up of an awful lot of neighborhoods.  But it takes a sincere intimate experience of each of those neighborhoods to get mutual responsibility going.

Full Circle America will I imagine also be seen by some people (it was initially by me) as a techno-gizmo for sale. It’s far, far, more than that, but there are techno-gizmos involved in its second money-saving idea. Teel monitors his patients with digital cameras, images relayed to a central facility where a technician evaluates images one, two, or more times per day, and automated algorithms trigger warning messages in the event of alarm-features. Opening the exterior door after midnight in winter, out of bed at night for more than 30 minutes, or in the bathroom any time for more than 90 minutes, for example. The inevitable privacy-invasion objection Chip counters by comparison to the much nastier privacy invasions in institutions. Most people would choose little cameras potentially watching their bedroom  all night at home over two or three hospital ward door- or curtain-openings without warning by staff with flashlights. By using this monitoring (and the technology gets more sophisticated all the time) people who would otherwise need a 24-hour paid person at home might manage with two 2-hour visits per day and round-the-clock computer surveillance.

Full Circle America isn’t perfect (what is?). I don’t quite share Dr. Teel’s belief in full generalizability of what he’s doing. I think the concepts of micro-cultural cooperation and the use of surveillance technology are portable, but dazzlingly comprehensive attention to detail, one of the program’s great strengths, might be reflected in a certain inflexibility as Chip struggles to reproduce it in other communities. It is at very least an important chunk of what we will eventually use to establish home care of frailty the way everybody knowledgeable knows it needs to be done.

Dr. Teel has confronted the problem many of us know so well, come up with original ideas (some of which have also independently occurred to others), and most critically made them work on the ground where he lives and works. Visionaries like him make the rest of us proud. Spreading the word, pulling networks together, and trying to be as practical as he’s been will I believe help us get where we want to go.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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One Response to New England Programs I: Full Circle America

  1. CLGD says:

    I like the idea of families, neighbours, communities helping. Years ago, after a big snowfall, I remember my Dad telling me to go shovel our elderly neighbours sidewalk (after being told to shovel our own sidewalk and dig out the car..) It was understood that our neighbour needed a hand with certain jobs and I was delighted to be of assistance. My Mum and Dad would also go over and play cards or visit or help with other jobs. Even my pet cat would wonder over and spend time with the old man next door (probably to get away from the noise of our own home – but, still, a feline visit was always welcome 🙂

    The reason this all worked is that we lived in a mixed neighbourhood. There were single people, young families, families of teens, middle aged people and older adults. We rubbed shoulders with each other. We benefited from our varied abilities and were able to help when and where there was need.

    I cringe when I see the number of developments that are restricted to adults only (age 19 +, age 35 +, age 55 +). This type of living arrangement does not build strong communities. The younger people do not benefit from the experience and guidance of the older adults and the older adults do not benefit from the help that the young people can give someone with whom they have a sense of relationship to and community with.

    I am a big fan of co-operative housing (both for affordability and for diversity). It is in this type of living arrangement, where there is stability and a variety of ages and family types, that community volunteers for older adults will be a natural.

    I very strongly believe that increased funding for affordable housing which is accessible (i.e for wheelchairs, lifts, and other features that would benefit seniors, people with disAbilities and families), close to community centers, schools, libraries, medical offices, etc. would help future fragile elderly stay at home and have their care needs met there.

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