PART VI: Arnold & Corinne Murray | March 9, 2014
A Cape Elizabeth couple, Corinne and Arnold Murray, seen here in their home recently as Corinne undergoes her twice-a-day mist treatment, have endured the kind of overwhelming medical ordeals that are common among Maine’s aging population. The crux of the issue, medical practitioners say, is that the way health care is being delivered now “does not match the needs of older folks.” Shawn Patrick Ouellette / Staff Photographer
CAPE ELIZABETH — Corinne Murray doesn’t remember much about the day she almost died.
Her husband, Arnold, recalls quite clearly the afternoon two years ago when he nearly lost the love of his life.
Corinne, then 85, was in the bathroom. It was about 4:30 p.m. and she hadn’t been feeling well all day. Arnold helped her to the toilet and went into the kitchen to warm up some soup for their supper.
Suddenly, Corinne let out a scream.
“I ran into the bathroom,” Arnold Murray recalls vividly. “She was standing up. I caught her as she fell and kept her head from hitting the tub. The ambulance came. They didn’t think they were going to make it to the hospital in time.”
Corinne Murray survived the trip to Maine Medical Center in Portland, where she was diagnosed with a ruptured abdominal aortic aneurysm and had emergency surgery that saved her life. But over the next year and a half, she wound up in the hospital five more times and stayed in three different rehabilitation facilities. Her sudden illness set the elderly couple on a long, often overwhelming and sometimes troubling path that many Maine seniors experience when they have catastrophic health problems.
As their numbers increase, thanks largely to advances in medicine and health care, Maine seniors more often find themselves on a nightmare merry-go-round managing several chronic illnesses, seeing multiple health care providers, enduring repeated hospital and rehab stays and taking a dozen or so drugs each day.
To make matters worse, the state faces growing shortages of geriatricians, primary care doctors and other health care providers who work with seniors. It’s a problem that will become more acute, because Maine’s population is aging faster than the rest of the nation.
The state’s median age – 43.5 years – is the highest in the United States, in part because Maine also has a dwindling younger population, according to the U.S. Census. The state’s proportion of people age 65 and older – 17 percent – is second only to Florida’s 18.2 percent.
Maine also has the nation’s highest proportion of baby boomers – 29 percent of its 1.3 million residents were born between 1946 and 1964 – and they’re turning 65 at a rate of 18,250 a year, according to AARP Maine. By 2030, more than 25 percent of Mainers will be 65 or older.
To adequately care for its growing senior sector, Maine needs more than 200 additional geriatricians and primary care physicians by 2030, according to national studies. And shortages of specialists such as rheumatologists and psychiatrists are expected to increase as current practitioners retire.
Further complicating matters, older Mainers also have some of the highest rates of devastating falls and debilitating depression in the nation, among other challenges highlighted in the 2013 Senior Report from America’s Health Rankings.
Arnold Murray reviews his wife’s drug regimen at their home. “He’s doing everything,” Corinne Murray says. “If it wasn’t for him. I’d be in a nursing home.”
Shawn Patrick Ouellette / Staff Photographer
Yankee independence, trust in the medical profession and lack of knowledge also conspire to keep many seniors from taking an active role in their health care. As a result, many don’t fully understand their illnesses or medications, and they’re reluctant to press their doctors for answers or even seek help in the first place.
If these circumstances are left unchecked, more and more Mainers will experience a health care landscape that is overwhelming, alienating and bleak when you’re old and sick.
Some hospitals and physician practices in Maine are taking steps to improve communication, provide more patient-centered care and reduce hospital visits, all in an effort to boost health outcomes and lower costs.
But these attempts are new and exclude many Mainers, and it’s unclear whether they will be widely accepted and expanded. Their efforts are further hampered by the state’s largely rural landscape and the limits of a statewide electronic record-keeping system that currently doesn’t include many smaller practices and most long-term care facilities and pharmacies.
One thing is certain.
“The way health care is delivered now does not match the needs of older folks,” said Dr. Robert Anderson, a professor of emergency and internal medicine in the Tufts University School of Medicine’s clinical program at Maine Med.
The Murrays are more familiar with the ups and downs of health care and hospitals than most people.
Corinne Murray was a registered nurse before she gave up her profession to care for two of the couple’s three children, both of whom had cystic fibrosis, a genetic disorder that affects the lungs most severely.
The couple moved to Connecticut for several years in the late 1950s and early 1960s to access the latest medical treatments for the little-known disease. When the Murrays’ oldest child, Carol Lee, first became ill, she had repeated bouts of pneumonia that stumped doctors in Portland.
“One doctor accused me of trying to find things wrong with her,” Corinne Murray recalls.
The Murrays are seen on their 25th wedding anniversary in 1973. The couple, an electrical contractor and a registered nurse, respectively, had three children, only the youngest of whom is still alive.
Carol Lee died in 1964, when she was 13. Their middle child, David, died in 1996, when he was 34. Their youngest, Alan, was born without the disorder. He’s an electrical contractor who lives in Michigan with his wife and daughter.
Still, the Murrays’ past experience with hospitals and heartache did little to prepare them for the spiral of catastrophic illness that swept them up in March 2012.
In the 18 months that followed, Corinne returned to Maine Med’s emergency room five more times for a variety of lung and neurological problems and a second serious fall. Each alarm led to another hospital stay and a stint in one of three rehabilitation facilities. With each transition, her list of prescription medications grew. The whole time she just wanted to be home, in the split-level ranch that Arnold Murray built for her in 1964.
Sitting in her living-room recliner, Corinne, now 87, recalls her ordeal. A colorful, crocheted throw is tucked around her lap and legs. A clear plastic tube trails from her nose, down the hallway, to a bedroom, where an oxygen tank gasps each time she takes a breath. Her husband sits nearby in his own easy chair.
Corinne Donna in her high school class photo from 1945.
“It was hard, it was discouraging and it was depressing,” she says plainly.
Following surgery to repair her ruptured aorta, Corinne Murray spent nearly a month in Maine Med before transferring to the New England Rehabilitation Hospital of Portland. A week later she made a second emergency trip to Maine Med with congestive heart failure.
Stabilized for a week, she returned to New England Rehab, where she spent a little more than a week before being discharged and sent home, according to her doctors.
Overall, the Murrays were happy with the care Corinne received, but they often felt overwhelmed, and wound up putting their trust in many people they had never met and would never see again.
“Every day it was a different doctor, and you wouldn’t know any of them,” says Arnold Murray, 85. “I couldn’t keep track. But my goal was to have her come through it, so I figured they knew what they were doing.”
Corinne Murray remained home through that summer, autumn and well into winter before making a third emergency trip to Maine Med in February 2013 with severe abdominal and back pain. She was diagnosed with ulcerative colitis and a broken vertebrae that doctors believe happened spontaneously because she has osteoporosis.
She was in Maine Med for several days before spending a few weeks at New England Rehab and returning home in mid-March 2013. Two months later, she fell getting out of bed and was rushed to Maine Med for a fourth emergency visit, this time for an undetermined neurological reason, possibly a seizure.
“She hit her head on a stool beside the bed,” Arnold Murray recalls. “She had a 4-inch gash in her forehead.”
She was in the hospital for several days before moving to the rehab facility at Piper Shores in Scarborough. On June 1, 2013, she was diagnosed with pneumonia and made a fifth emergency visit to Maine Med. She stayed in the hospital overnight, then returned to Piper Shores, where she remained until mid-July. Then another possible seizure sent her back to Maine Med for a sixth time.
She was in the hospital for a week before being discharged for rehab at the Springbrook Center in Westbrook. She stayed there for a few weeks, then returned home in August for the first time in six months.
“She always wanted to go home, and I knew I could take better care of her,” Arnold Murray says. “When you go from one place to another and you don’t know anybody or what they’re doing, you just want to go home.”
Dr. Robert Anderson a professor of emergency and internal medicine with the Tufts University School of Medicine’s clinical program at Maine Medical Center in Portland, speaks with the Murrays during a home visit in November. He spends two days each week going on house calls to see elderly people who have visited the emergency room or have been referred to him by other doctors. Below left, Corinne Murray reacts during his visit. Dr. Anderson, who speaks publicly about the various challenges facing older adults, says he often finds seniors having trouble managing their medications or living among conditions – such as steep stairs or exposed electrical cords – that potentially threaten their health and safety. Shawn Patrick Ouellette / Staff Photographer
Corinne and Arnold Murray are luckier than many Mainers.
Dr. Anderson, the clinical professor at Maine Med, was on duty in the emergency room the day Corinne first got sick. Anderson has a special interest in geriatrics, so he makes house calls two days a week with patients who’ve been to the ER. He has visited Corinne at home a few times in the last two years.
“We had a special bond because she came into the emergency department when I was there and I diagnosed her and helped to save her life,” Anderson said. “So I got to know her as a patient first. Then, by visiting her in her home, I got to know her as a person, which is an important part of good health care.”
In addition, Corinne’s primary care physician, Dr. John Reynolds, is a partner in Cape Elizabeth Internal Medicine, a practice that’s part of the Maine Medical Center Physician-Hospital Organization.
Corinne listens to Dr. Robert Anderson during a home visit
Shawn Patrick Ouellette / Staff Photographer
So each time Corinne returned home, Michelle Tarr, a registered nurse care manager who works with Reynolds, visited her a few times. She also called regularly to monitor Corinne’s recovery, to help manage her medications and to coordinate her follow-up care.
Tarr’s help means a lot to Arnold Murray, because he’s in charge of Corinne’s medications and overall care. While he takes a few pills each day for blood pressure, cholesterol and arthritis, Corinne, a former smoker, takes more than a dozen medications for conditions ranging from colitis to chronic obstructive pulmonary disease, or COPD, which includes emphysema.
Arnold doles out Corinne’s meds as directed on a chart drawn up by Tarr. To keep track, he separates the pills into a rainbow-colored plastic box that has several covered compartments for each day of the week.
“She helps us more than anybody else,” Arnold Murray says of Tarr. “Whatever the problem, we can call her.”
Shawn Patrick Ouellette / Staff Photographer
Maine Med and its affiliated physician practices started employing registered nurse care managers like Tarr several years ago because they believed it would benefit their patients and their bottom line.
Tarr’s work falls within a larger effort by several agencies, including Maine Quality Counts, to establish so-called “patient-centered medical homes” across the state.
The pilot program is in its fifth year and includes 160 practices, said Dr. Lisa Letourneau, executive director of Maine Quality Counts. Part of a national trend, the goal is to improve care, reduce costs and keep people well and out of the hospital.
Medical practices involved in the pilot are paid separately to provide transitional care that otherwise would go unpaid under a traditional fee-for-service model.
“We’re trying to change primary care to be more patient-centered instead of just waiting for people to show up when they’re sick,” Letourneau said.
But while 160 physician practices in Maine are involved in the pilot, they only cover about 600,000 of Maine’s 1.3 million residents, Letourneau said. Many of the state’s smaller, independent practices haven’t joined, in part because they don’t have the staffing and technology to participate.
And while Medicare, Medicaid and the state’s three major private health insurance providers have supported the pilot’s alternative payment structure, it’s unknown whether that support will continue and expand to encompass other Mainers, Letourneau said.
in their words
an interview with Arnold & Corinne Murray
Before Corinne Murray got sick in March 2012, she hadn’t seen Dr. Reynolds, her primary care physican, in five years. She was relatively healthy, active and didn’t see a need for it.
She did all of the housework and cooking, regularly baking apple pies that her husband devoured. She tended their garden, drove to the supermarket and attended weekly club meetings with other ladies in town. Her only prescription medication was for high cholesterol.
Arnold Murray explains their mindset back then.
“Somebody who’s feeling good, you think twice before you spend $150 on a physical, especially if you’re living on Social Security,” he says.
Corinne sees things differently now.
“At our age, we should be seen more often,” she says.
To get more seniors to embrace preventive care, Medicare now pays for annual wellness checks, as well as regular care for chronic illnesses, said Letourneau, of Maine Quality Counts.
Still, persuading frugal, independent Mainers to visit the doctor when they’re well, or take other steps that may keep them healthy, isn’t so easy, said Larry Gross, executive director of the Southern Maine Area Agency on Aging.
“There seems to be an ethic among older Mainers that says, ‘I’m independent, I can do things on my own,’ ” Gross said. “There’s also a Yankee stoicism that leads people to think, ‘If I don’t go to the doctor, I won’t know how sick I really am.’ We’re asking people to change that behavior.”
Some medical practices, including Cape Elizabeth Internal Medicine, are trying to increase regular communication with patients, reminding them when they should have a routine physical or a cancer screening. But that became possible only recently because of electronic medical records, and many practices still wait for patients to call in.
“It amazes me that many veterinarians and dentists have better systems in place to notify patients than many doctors,” Gross said.
Corinne Murray moves from the kitchen to the living room with the help of a walker at her home. Shawn Patrick Ouellette / Staff Photographer
Maine ranked 13th in the nation in a recent first-time, comparative assessment of senior health by America’s Health Rankings. But the 2013 Senior Report found several problems that affect the health and health care of Mainers age 65 and older.
Started in 1990, America’s Health Rankings is a yearly report on all age groups based on data from various sources, including the U.S. Centers for Disease Control and Prevention, the American Medical Association and the FBI. The rankings are published by the United Health Foundation, an independent nonprofit established by UnitedHealth Group, a Minneapolis-based health insurance and service company.
Here’s how Maine ranked among the 50 states in the following areas:
Corinne and Arnold Murray are fortunate that their primary care physician has taken an interest in geriatric issues, and that Maine Med has a geriatric center, which caters to the needs of older adults and promotes geriatric health care practices throughout the hospital organization.
Cape Elizabeth Internal Medicine started an initiative this year to talk with every older patient about falls and how to prevent them, Dr. Reynolds said. Maine has the eighth-highest fall rate in the nation, with 18.2 percent of adults age 65 and older reporting they had fallen in the previous three months, according to the 2013 Senior Report from America’s Health Rankings.
Because Maine has a shortage of geriatricians, other health care providers must increase their attention to falls, drug interactions and other challenges that come with aging, said Dr. Roger Renfrew, a geriatrician who practices in Skowhegan.
Renfrew recently led the effort to organize the Dirigo Maine Geriatrics Society, a chapter of the American Geriatrics Society. The newly formed board of directors represents various health care fields.
“The primary goal is to support our colleagues in primary care and elsewhere to provide necessary geriatric care for all older Mainers,” Renfrew said.
Maine had 48 certified geriatric medical doctors in 2012, when it needed 42 additional geriatricians, according to the American Geriatrics Society. With anticipated growth in the senior population, it will need a total of 160 geriatricians by 2030.
Maine also has a shortage of nine primary care physicians in rural areas, according to the U.S. Health Resources and Services Administration, and it needs seven additional psychiatrists.
The shortage of primary care physicians is expected to grow to 120 by 2030 because of the increasing senior population and the number of people insured under the Affordable Care Act, according to the Robert Graham Center in Washington, D.C., which studies public policy in family medicine and primary care.
The Maine Medical Association doesn’t keep track of geriatricians, but it does count rheumatologists. Maine had 16 of those specialists in arthritis, osteoporosis and autoimmune diseases in 2013, and several of them were eligible for retirement, said Gordon Smith, association spokesman. Some new patients wait months for appointments.
Corinne and Arnold Murray are reluctant to criticize the care they received in the hospital or in rehab facilities. They’re mostly glad she survived and is feeling a little better every day.
But they admit they’ve had some troubling experiences. Arnold says he was upset when he saw Medicare charges for psychiatric consultations he thought Corinne didn’t need.
Corinne says she was mortified when she was bathed by a male health aide who looked to be about 18 years old. Another aide refused to help her pull up her pants, saying that she should learn to do it herself.
“She said, ‘What are you going to do when you’re on your own?’ ” Corinne recalls. “But I could barely reach. It was painful.”
Some hospitals are taking steps to improve the way they treat older Mainers.
Redington-Fairview General Hospital in Skowhegan adopted guidelines last year to help staff members recognize and avoid bias in communicating with seniors, said Dr. Michael Lambke, a family practitioner who is the hospital’s medical director.
“We knew we weren’t doing as well as we could,” Lambke said. “None of us has been old before, and clearly we have a difficult time imagining what it’s like to be 75 or 85 years old.”
In addition, when the emergency department receives nursing home residents with cognitive issues, such as dementia, a staff member calls the nursing home to get current health information about the patient, Lambke said. In the past, when nursing home patients couldn’t speak for themselves, staff members relied on instructions from paramedics.
MaineGeneral Health is making similar efforts to improve geriatric care, said Dr. Steven Diaz, an emergency room physician who is MaineGeneral’s chief medical officer.
This summer, the health group will hire two new administrators who will be tasked with improving inpatient care for seniors and outreach to a variety of geriatric care providers in surrounding towns, Diaz said.
“Just by virtue of us being the largest health care provider in our area, it’s incumbent upon us to be a leader in a collaborative way on this issue,” Diaz said. “We’d like to think that we’re meeting everyone’s needs, but we know that isn’t the case.”
Arnold Murray tucks a quilt around Corinne as his wife settles into the recliner where she spends much of her days. She admits that she gets a little down sometimes. “But I don’t let (Arnold) know because it would make him depressed,” she says. In Maine, almost 1 in 5 adults 65 or older report having depression. Shawn Patrick Ouellette / Staff Photographer
Arnold Murray is familiar with hard labor. A retired electrical contractor, he worked well into his 70s, when arthritis in his knees forced him to put down his tools. He followed in the footsteps of his grandfather, who built several prominent local buildings, including the town hall.
He’s proud that he never had to advertise because he was known for doing good work.
“I used to tell my crew, ‘If you can’t do it right, don’t do it at all,’ ” Arnold Murray says.
Now he spends his days taking care of the woman he started dating when they were students at Cape Elizabeth High School. Moving slowly and carefully with a cane, he prepares their meals and does a little housework each day.
He dusts their collections of miniature lighthouses and other knickknacks. He waters their houseplants, including a field of African violets on the coffee table. He keeps the upright vacuum cleaner in the dining room for easy access.
Arnold brushes off the suggestion that health care providers recommend removing scatter rugs and other furnishings to help prevent falls.
“I make out all right,” he says. “I’m not fast, I’m just careful.”
He helps Corinne bathe and dress. He makes sure she exercises. He watches her every move as she rambles from one room to another with the help of a walker.
“He’s doing everything,” Corinne says. “I wipe the dishes and I surprise him once in a while and make the bed when I feel up to it. But if it wasn’t for him, I’d be in a nursing home.”
Corinne admits that she gets a little down sometimes.
“But I don’t let (Arnold) know because it would make him depressed,” she says.
Maine has the third-highest rate of depression among seniors in the nation, with 17.8 percent of adults age 65 and older reporting they have the disorder. She takes medication for it, but Arnold has a strategy for staying positive.
“We don’t dwell on stuff or feel sorry for ourselves,” he says. “When no one shows up to see us, I tell her we’re lucky we have each other.”
The two are rarely separated because he doesn’t want to leave her alone. A few friends and family members call regularly to check on them, keep the snow cleared and run errands at the pharmacy or grocery store. Their son Alan calls daily and has come for several long visits since Corinne was ill.
But mostly Corinne and Arnold Murray are on their own. When she has a doctor’s appointment, he drives her there. After 70 years together, they can’t imagine being without each other.
“I wouldn’t be very happy alone,” Arnold Murray says, then turns to his wife. “I didn’t like it when you were away all that time before.”
They’re grateful that Medicare has paid for most of Corinne’s medical expenses and concerned that their savings won’t last. “We put enough away when I was working, but it’s going fast,” Arnold says. “God help the people who aren’t putting enough away today.”
They’ve considered moving to an assisted-living facility, but Corinne won’t have it. “She says, ‘You built this house for me and I’m going to stay here,’ ” Arnold says.
If all goes well and Corinne gets a bit stronger, they’d like to spend some time this summer at the seaside cottage that’s been in Arnold’s family for decades.
“We haven’t been there for two years,” Corinne says. “I hope we get there this year.”
Part V: James and Nancy Pike
Across Maine, there's an increasing number of people like Jim and Nancy Pike of Alfred, seniors whose declining health and limited finances have put them among the so-called 'food insecure.' 'They are the hidden hungry … and they don't want anybody to know.'
HEALTHCARE AND THE ELDERLY
Taking multiple drugs and supplements is common among Maine’s aged, ‘a necessary chore.’ It’s up to doctors, pharmacists, caregivers and the patients themselves to ‘treat carefully’ and avoid risks.