FEATURE STORY — Mar./Apr. 2007

Backseat Doctor

Four days a week,
Dr. Thomas Cornwell
takes his medical practice
on the road, bringing health care to the homebound

By Kevin McKeough
Photography By Lloyd Degrane

Aldona Milauckas hasn’t left her house in three years. In fact, the 88-year-old woman’s emphysema has become so severe that she no longer even comes downstairs from her bedroom on the second floor of the home she shares with her daughter Patty.

She’s understandably excited to have a visitor on this sunny Friday afternoon in mid-October. Dressed in blue pajamas, Milauckas sits perched on her bed, a tube running from her nose to the oxygen tank that puffs in the corner. Dr. Thomas Cornwell, MD ’86, sits across from her, stethoscope slung over the shoulders of his blue lab coat, reviewing her list of medications.

“I gargle with Tylenol,” she tells him. “Never heard of it,” Dr. Cornwell jokes, as Joanne Gonzalez, his medical assistant, gives Milauckas a flu shot, takes her blood pressure and examines her ears.

Cornwell asks Milauckas about her breathing, chest pains and anxiety, in addition to her meds. “You’re telling me how you’ve doctored yourself. You don’t need me,” he teases her.

“I need you, I need you,” Milauckas implores, clutching his hand.
These sorts of interactions are an everyday part of Cornwell’s practice. While house calls are a relic of the past for the vast majority of physicians, they are Cornwell’s sole focus. He’s been providing home health care to patients such as Milauckas since 1993, and last December completed his 20,000th house call.

His practice, HomeCare Physicians, currently provides care for about 800 homebound patients in a two-county suburban area west of Chicago. Most of them are elderly and physically infirm—the average age of his patients is 80—and many are incapacitated mentally due to conditions, such as Alzheimer’s disease and strokes. Cornwell also treats younger patients who have neuromuscular disorders, such as muscular dystrophy and multiple sclerosis.

“If we didn’t come to them, a lot of these patients would have very limited or no access to health care at all,” observes Dr. Paul Chiang, MD ’89, who joined HomeCare Physicians in 2000 and recently completed his 10,000th house call. “We’re meeting the needs of a very disenfranchised group of people.”

Both evangelical Christians, Cornwell and Chiang see their practice as a form of ministry. In fact, Dr. Cornwell comes from a long line of Lutheran ministers and originally planned on following in their footsteps. However, as an undergraduate student at St. Olaf College in Minnesota, he discovered he didn’t possess the necessary aptitude for writing and public speaking and, at an adviser’s suggestion, pursued medicine instead.

A native of suburban Palatine, Cornwell then attended UIC’s College of Medicine, where he received the William J. Grove Outstanding Medical Graduate Award for academic achievement and leadership.

He praises the College’s medical faculty for their dedication to teaching and hands-on interaction with patients, both of which were central to his education. “You get a great clinical experience at UIC,” says Cornwell, whose wide blue eyes and full head of dark, neatly cropped hair give him a boyish look that belies his 46 years. “As a student, I was given the chance to have a lot of hands-on clinical experience with patients—things like drawing blood, starting IVs, taking histories and performing physicals—at an early stage in my career.”

Resuscitating home doctor visits

After completing his residency and working for a clinic, Cornwell was recruited to begin a home care program in 1993. When the program ran into financial difficulties, Cornwell partnered with Winfield-based Central DuPage Health, his previous em-ployer, to establish HomeCare Physicians, which began caring for patients in 1997.

HomeCare Physicians has helped reverse a nationwide decline in physician house calls that dates back to the 1930s. Whereas 1 in 11 doctor visits took place in the home in 1958, by 1980 that ratio had decreased to 1 in 167, according to a University of Maryland study. This decline is attributed to increased patient mobility, the increasing amount of stationary technology involved in health care and, above all, financial disincentives.

Since 1998, though, the annual number of house calls has increased by 43 percent, from 1.4 million to 2 million, according to a Journal of the American Medical Association study. Home health practitioners expect that number to grow rapidly as baby boomers age.

Meanwhile, the financial picture for home health care has brightened. In 1997, the highest Medicare payments for house calls were less than the maximum payment allowed for new office visits, and reimbursements for the most common forms of home health care were less than rates for home visits by nurses, therapists and social workers. Medicare rates have doubled since then, but the logistics of house calls limit Cornwell to an average of 10 patient visits a day, half the amount he could manage in a clinic.

To make HomeCare Physicians financially viable, Cornwell relies on a $250,000 a year subsidy from Central DuPage Health, plus donor contributions. To date, he has received more than $1.5 million in donations, including a $300,000 gift that established an endowment to pay for medical needs that Cornwell’s patients can’t afford, including medications, lift chairs and utilities. Cornwell is also planning a 10-year celebration and fundraiser, which was held in March.

While providing home care presents financial challenges for Cornwell, he stresses that it saves costs overall by reducing patients’ needs for ambulances, emergency room visits and hospitalization. “I can do 12 visits for the cost of one day in a hospital,” he notes.
According to Cornwell, treating patients in the home also enables him to provide them with better care, because he can fully assess their circumstances. “We have found people with no food in the house. We’ve had a patient on 100 vitamins, double dosing on generic and name brand medicines,” he says. For these homebound people, knowing their environment allows Cornwell to provide better care.

“I feel like I get better attention with this home service than I did going to a private doctor,” says 80-year-old Margaret Abate, who credits Cornwell for helping her stabilize her diabetes. “He’ll talk to me about what I’m supposed to do. I can ask him a question and get an answer.”

Technological advances have also im-proved the level of care that physicians can provide in patients’ homes. The back of Cornwell’s dark blue 2002 Ford Explorer includes a portable electrocardiogram, and Chiang brings an ultrasound machine on his patient calls. In addition, Cornwell can arrange for a service to take X-rays of patients in their homes. His Treo cell phone has a prescription drug database that enables him to determine the interactions for as many as 21 medicines.

Making the rounds

At 8 a.m. four days a week, Cornwell and his medical assistant Gonzalez leave the HomeCare Physicians office in their SUV. Each day’s carefully planned itinerary focuses on a specific portion of Cornwell’s practice area, so that most of the homes he visits are less than five miles apart.

As Gonzalez drives to this day’s appointments, Cornwell sits in the back seat, completing paperwork taken from files he keeps in a milk crate by his side and doing a fair amount of backseat driv-ing. He also makes phone calls, ordering patients’ prescriptions, scheduling diagnostic tests and consulting with caregivers. Cornwell gives patients his cell phone number, and the Treo seems to ring at least once during each house call.

There’s a bit of the fast-paced feel of a television medical drama in the way Gonzalez and Cornwell roll up to each home and quickly disembark the SUV, pulling along a hand cart with bags containing a blood draw kit, medical supplies and refrigerated flu vaccines. While the primary purpose of this day’s round of house calls is to give patients their flu shots, Cornwell uses each visit to review the medical conditions of patients, going over a litany of questions with them or their caregivers.

Usually, he stays longer than planned in order to address new medical developments. On his second call of the day, Cornwell confers with the daughters of a 100-year-old woman suffering from trigeminal neuralgia—a nerve disorder that causes excruciating shooting pains in the face—about adjusting the patient’s medication to relieve the pain without leaving her in a stupor.

“A lot of doctors have a handful” of patients with “hugely complicated” cases, notes Cornwell. “But with our patients, it’s almost a prerequisite that you be horribly sick [in order] for us to care for you. That can be challenging. It’s one difficult condition after another, not five blood pressure checks.”

One such case is Kenya Porter, a bedridden 30-year-old woman with scleroderma, a connective tissue disorder that causes hardening of the skin. Her medications are causing cramps, so Cornwell changes her prescription and recommends milk of magnesium, taking care to explain how the familiar over-the-counter treatment works.
“He doesn’t mind explaining things to me and he doesn’t talk to me like I’m a patient. He really cares,” Porter says during a phone interview a few weeks later. Since Cornwell’s visit, the cramps have gone away, but she’s developed a bladder infection. Informed of her symptoms, Cornwell calls in a prescription, sparing Porter a trip to the emergency room.

“I know he has a lot more patients than just Kenya, but when he’s talking with her, he makes it seem like she’s the only patient he has to care about,” says Kenya’s mother, Janice Porter. “He listens to not just what her medical problems are, but the things we’re going through on a daily basis. It helps to talk [about] some of the issues we have on an emotional level, the stress level.”

Applying his ministerial skills

It’s clear that Cornwell’s practice entails not only providing medical care, but emotional comfort to his isolated patients and the family members who have the difficult responsibility of looking after them. In keeping with his religious faith, this care often extends to spiritual ministry, and Cornwell sometimes concludes his visits by praying with his patients.

“Thank you for this woman,” he says with his head bowed, holding Aldona Milauckas’ frail hand. “I thank you for how she lifts us up.

“You are such an inspiration,” he tells her, kissing the top of her head as she wipes tears from her eyes.

For Cornwell, his practice is a way of living out his faith and calling to help others. That sense of mission sustains him in his work through the financial constraints, the physical demands of carrying equipment, the severe conditions of his patients and the sometimes off-putting state of their homes.

Despite these challenges, he takes great fulfillment in seeing the positive outcome of his work. “The greater the challenges, the greater the difficulty, the greater difference you can make,” Cornwell says. “Even though the situations are bad, you have a great opportunity to make them better.

“I see miracles every day,” he says. “I live with such joy.”