Pt Refused to Get Stuck Again
Stuck in Bed, at Hospital's Expense
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ON January. 4, 2010, Raymond Fok was changing trains on his mode to kidney dialysis treatment when he complanate on the Canal Street subway platform. Emergency medical technicians examined him and took him by ambulance to the nearest hospital, New York Downtown, near the foot of the Brooklyn Span. Workers in the emergency room recorded that Mr. Fok's speech was slurred and that he was lurching from side to side when he walked.
"He was a very typical hemorrhagic stroke," said Jeffrey Menkes, the hospital'southward president. From the emergency room, the hospital admitted Mr. Fok to the intensive-care unit on the third floor, where workers tried to find out more nigh their patient — non just his medical history, simply his insurance or Medicaid status, his address, his Social Security or taxpayer identification number, the location of family members.
One time his condition had stabilized, the hospital moved him to a regular room on the fifth flooring, where staff members expected to treat him for 7 to 10 days before discharging him to a sub-astute-care center for rehabilitation, the usual regimen for stroke victims.
19 months after, Mr. Fok, 58, greeted a reporter from his bed in Room 516, eager to accept a company. In the previous yr and a half, perhaps 100 or more patients had come and gone from the room'due south other bed, but Mr. Fok had gone nowhere. "Yes, I remember y'all," he said. "John, right?"
The toll of his treatment: $1.four 1000000.
And who was paying for it?
"The authorities," Mr. Fok guessed, though he was not sure. "The hospital is losing money."
In a city with a big immigrant population, it is not rare for hospitals to take ane or more patients who, for reasons unrelated to their medical status, do not seem to leave. At Downtown, where a bed costs the hospital more than $2,000 a day, there are currently iii long-term patients who no longer need acute care but cannot be discharged because they accept nowhere to go. The hospital pays nearly all costs for these patients' handling. 1 man left recently after a stay of more than five years.
They are the forgotten people in the health care organization — uninsured, usually undocumented, without resources and stuck in the system's most expensive class of care. Some are abandoned by or estranged from relatives; some belong in rehabilitation centers, where care is much cheaper, but because of their immigration condition they are not enrolled in Medicaid or Medicare, so the places will not take them. For hospitals, some of these patients, similar Mr. Fok, come up in as medical cases and then quickly become puzzles for detective work.
Mr. Fok released the hospital to discuss his treatment, which involved every section of the staff, from laundry and food services to psychiatric care, social piece of work and community outreach.
"The outset two or three months was a hard time," Mr. Fok said from his hospital bed, the left side of his face even so partially frozen from the stroke. He had a tattoo around ane arm and 2 lumps on his blank leg where the dialysis needles removed and then returned his blood 3 times a week. He has spent 23 years in the The states, only his English remains rudimentary.
In the beginning, he said, "always I idea, how long before I go out? Because when you wake up in the same room every twenty-four hours it's the same matter, 'When I can get out?' It's always depressing. Just 24-hour interval by day, day by day, you don't need to worry almost what will happen, because when yous wake up it'southward ever the same room."
RAYMOND FOK was born in Madagascar and grew upwardly in Hong Kong, where he became a constabulary officer. In 1988, he brought his wife and two young sons on what he told officials was a holiday in New York, and and so never returned. Mr. Fok left some question about his reasons for overstaying the family's tourist visas, repeating that he had feared Hong Kong's approaching handover to the Chinese government, though at the time this was nine years away.
In New York he found a job at a vegetable market in Chinatown, earning $v an hour to feed a family of four — and soon, with the birth of his daughter 18 years ago, 5. A friend helped him rent an apartment in a heavily Chinese section of Bensonhurst, Brooklyn, and taught him to navigate the subways. Simply the friend refused to help him employ for permanent residence, Mr. Fok said.
Somewhen he landed a chore driving a truck for a Chinese-owned company in New Jersey, at $400 a week, off the books, with no insurance benefits, he said. He had a driver's license and bought a car to commute.
"Brand a life, pay hire, support a family," he said. His wife worked in a laundry on Delancey Street. His sons went to school and afterwards found jobs in bodegas or bagel shops. It was enough.
But driving was stressful, with no extra pay for overtime, and he lived on fat foods consumed on the go. When his kidneys failed, an emergency-care provision in Medicaid paid for dialysis treatments, though he was otherwise ineligible for coverage.
For Mr. Menkes at New York Downtown, any day the emergency room door might let in the next Mr. Fok. Nether federal law, hospitals are required to treat anyone who comes in, regardless of his or her immigration status or ability to pay. Half of the in-patients at Downtown are Asian immigrants, many of them undocumented, Mr. Menkes said. Forty-five percent of those on the staff speak at least ane dialect of Chinese. When Mr. Fok arrived — with no Social Security number, no green card, no insurance, disoriented, no known family unit or address — the infirmary was ready for him.
Downtown Infirmary, which has an annual operating budget of $200 one thousand thousand, runs at a slim margin, Mr. Menkes said. Iii-quarters of its patients receive either Medicaid or Medicare, which have cut reimbursement rates for doctors, even as expenses accept risen. Many private doctors have stopped seeing Medicaid patients, merely for the hospital, a individual nonprofit establishment, this is not an option. The hospital loses money on most babies it delivers, Mr. Menkes said, because reimbursement rates fall below the toll of delivery in New York.
Mr. Fok came in the door a sick man. He had kidney failure, hypertension and a weak heart, in addition to having suffered the stroke. He could not eat because of a swallowing disorder caused by the stroke. His left side was immobilized.
"While he was in I.C.U., he said he wanted to die," said Norma Robinson, a case director in the hospital's continuum of care department, which coordinates a patient's physical and emotional handling. "Psych came in. A social worker evaluated him. He said he had a son but didn't know the son'south name."
So began a mission by the hospital staff to reconstruct the identity of Raymond Fok, with fiddling cooperation and sometimes active interference from the patient. The family unit had no country telephone line, and Mr. Fok said he did not know anyone'southward cellphone number. The detectives were starting from scratch and could not necessarily trust their prime source.
In the infirmary's favor, Mr. Fok had no one else to talk to. He had very few visitors, and his roommates changed every few days, before he could bond. "We were his visitors," said Chui-Man Lai, an assistant vice president of patient services, community outreach and provider relations. "That's why data comes upwardly to the surface flake past chip. Mr. Fok didn't want to expose his family unit, considering the whole family unit is undocumented." (His daughter is actually a United states citizen.)
Gradually, nuggets of information came to lite. "He said, 'I have two sons merely I'thousand not associated with them,' " Ms. Robinson said. He said that his wife worked in a laundry just that he did not know the name or number. For nearly a year, according to staff members, Mr. Fok declined to provide any other data virtually his family. He sometimes refused physical therapy or spoke inappropriately to the therapists, said Sharon Fan, a social worker. Ms. Robinson instructed the nurses to watch out for family unit members visiting him.
When his wellness became stable, Mr. Fok no longer needed the astute-level care the hospital provided. The administrators tried to observe a less plush home for him.
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"No nursing home would take him because he had no Medicaid and no light-green carte du jour," Ms. Robinson said. Early on this twelvemonth, after more 12 months of treatment, employees had a brief glimmer of hope. An evening nurse spotted a woman who seemed to be Mr. Fok's wife visiting the room. But hopes were curt-lived. "She said she can't take intendance of her husband," Ms. Lai said. The staff redoubled its surveillance, only never saw her once again. "It was just that in one case," Ms. Lai said.
Mr. Fok told the hospital that he lived in a five-story walkup, which made going home all but incommunicable. He needed regular transportation to dialysis, and even if he had Medicaid, the transportation providers carry patients upwardly or down only two flights of steps, said Emma Turner, an administrative supervisor in the continuum of intendance department.
In fact, the Foks' flat is on the ground floor, just five steps upward from street level.
"He didn't belong here," Mr. Menkes said. "But what's the alternative?"
TO a stranger coming together Mr. Fok for the offset time, he tin can seem eager for chat, candid virtually his life. One one-time roommate described him as affable and talkative. He loved soccer. He hated the hospital food. On an Baronial 2011 morning at the infirmary, he described the strained family situation in Bensonhurst.
"My sons detest me," he said. "They say, 'Why you bring me here? You don't have idea. You bring me here; it was a mistake.' I don't recall information technology was a fault. When y'all come hither you see a lot of the earth. In Hong Kong you run into just a piddling bit of sky, but here y'all can come across a big heaven, a lot of people, unlike people. It's the upper-case letter of the world, New York. Different people, different cultures. Simply they don't like it."
He added: "I'1000 non worried about it, because I got to accept intendance of myself, commencement. And second, when they grow up they will sympathize. One day they will have families and they will understand, too."
His sons, who he said are 29 and 22, declined to exist interviewed for this article. His girl deferred to her brothers.
With Mr. Fok unable to work, the others had to pay the $1,200 monthly rent without him. He said his sons paid just the electric beak, so they could run the computer and air-conditioner; for the residual, his wife worked 13 hours a twenty-four hours, seven days a calendar week at $five an hour. She had piffling fourth dimension to visit him in the infirmary — and no time to take care of him should the hospital discharge him.
New York's Department of Social Services allows Medicaid and other welfare benefits to illegal immigrants who can demonstrate that the authorities does not intend to deport them, or who have an immediate relative who is a citizen and files an application on their behalf. Getting the first kind of documentation can take a year or more, Mr. Menkes said. Simply for Mr. Fok, the second, quicker, option was besides possible. His daughter, who was born in New York, was about to turn 18, and could apply for him to receive benefits equally what is known equally a person permanently residing under colour of constabulary, or Prucol. There was only one problem: no ane knew how to reach her.
"We continued to feed him, do his laundry, provide nurses and doctors," Mr. Menkes said. "But he doesn't belong in an astute-intendance hospital." By early 2011, his neb had risen past $i 1000000, of which the hospital was receiving reimbursement simply for his dialysis treatments, which were less than one-10th of the total costs.
Finally, in March, there was a breakthrough. Mr. Fok was making progress in physical therapy, and staff members told him he could walk if he had a lightweight device called a hemi cane or hemi walker — basically a cross between a pikestaff and a walker, designed for people with use of only 1 arm.
"I'one thousand good with faces," Ms. Robinson said. "I come up out of the elevator and I see a girl who looks just like him, carrying a hemi walker. I said, 'Who are you lot?' She said, 'I'1000 Mr. Fok's girl.' "
ON Aug. 17, subsequently one year, 7 months and 13 days, Mr. Fok returned to his apartment in Bensonhurst, conveying 21 filled prescriptions and his hemi walker. For the $1.iv million in services that Downtown had provided, total reimbursement to the infirmary from Medicaid was $114,000, Mr. Menkes said.
Mr. Fok'southward immigration status never kept him from receiving handling, simply it helped make sure that his care would exist delivered in the most expensive setting possible and in a place no one wants to spend more fourth dimension than necessary. He was cut off from his family. On several occasions he showed signs of low or expressed suicidal thoughts.
If he had been insured or immediately eligible for Medicaid or Medicare, he might have gone to a nursing home after a week or two, where the average daily cost in New York is about $350 — and where he might accept had steady companionship. Or he might have received a home health adjutant in his apartment, which could have price even less, depending on the required hours.
For hospitals like Downtown that treat many illegal immigrants, the health intendance plan enacted terminal year does zilch to solve this liability, Mr. Menkes said. During debates nearly reform, lawmakers insisted that the plan's benefits not extend to the nation's eleven one thousand thousand illegal immigrants.
Lawmakers now are proposing cuts to Medicare and Medicaid to reduce the deficit, which may put fifty-fifty more pressure on hospitals similar Downtown. Nor is this likely to change. Few politicians who want to be re-elected will advocate broadening public services to illegal immigrants or increasing the taxpayer price of health intendance.
For Mr. Fok and his family unit, the render home has been difficult. After his discharge, he did not immediately become a dwelling house health aide. In a family already stressed financially and with difficult relationships, having a patriarch who needs total-time care has raised the tension levels. No i had time before; how could they at present?
In late August, Mr. Fok's older son called the hospital, irate.
"He said, 'It's an unsafe discharge; I'm going to report you to the attorney general,' " Ms. Robinson said. " 'Have him dorsum.' I said, 'No, we're not going to take him dorsum.' He said: 'I work and I take care of the flat. Take him back. I desire to finish college, and I have a year and a half to go.' "
On a mid-September afternoon, about ane calendar month after his discharge, Mr. Fok sat in a wheelchair in the crowded waiting room at Chinatown Dialysis Center, a long ambulette ride from Bensonhurst. His hair and beard were neatly trimmed, and he wore a spotless T-shirt.
He was glad to exist home, he said. "Yep, of course."
Merely equally the conversation continued, he reversed this statement. He spoke in tired monosyllables and did not make eye contact, as he had in the infirmary.
Since he came home, his sons have been aroused at him, he said: "Because I give them a hard time now. They got to take care of me."
He cannot set up nutrient for himself or walk to the door to open up it. He needs help getting to the bathroom. He said he had not walked since leaving the hospital, even with the hemi walker. Asked if he would rather be dorsum in the hospital, he said aye.
"I'd like to go back just cannot," he said. "What reason to get dorsum?"
Source: https://www.nytimes.com/2011/10/02/nyregion/stuck-in-bed-for-19-months-at-hospitals-expense.html
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