How the house call may be the future of medicine

Healthcare in the 1930s: Back then, 40% of patient encounters occurred in the home, and it was a time that characterized, even idolized, the physician and his iconic black bag of cures. By 1950, the house calls were vanishing because of the centralization of medicine and advances in equipment.

But the norman Rockwell image of the family doctor paying a house call is making a comeback, and it is being driven by technology, the societal need to care for an aging homebound population of patients, and payment models that will reward care and reduce hospital admissions.

The comeback

According to data from Medicare Part B billings, the number of house calls increased from 1.4 million visits in 1999 to 2.3 million in 2009. Part of the reason is the graying of America-by 2030, 70 million of us will be aged more than 65 years. And the American Academy of Family Physicians (AAFP) expects the demand for house calls to increase because the existing long-term care and assisted living infrastructure does not have the capacity for the increasing numbers of elderly patients needing services.

More and more, the house call is becoming a tool for primary care physicians to provide access and reduce institutionalization of their elderly patients by delivering care in the ultimate patient-centered home: the patient’s home.

The Affordable Care Act supports the idea of the house call through many initiatives, including accountable care organization (ACO) pilots and Patient-Centered Medical Home (PCMH) pilot projects.

The Independence at Home Act demonstration project through the Centers for Medicare and Medicaid Services (CMS) Innovation Center is a 3-year project begun in 2012 that will test the effectiveness of delivering comprehensive primary care services at home, the ability to improve care for Medicare beneficiaries with chronic multiple conditions, and the success in rewarding healthcare providers who reduce costs through quality care.

The U.S. Department of Veterans Affairs’ Home-Based Primary Care program, which uses a multidisciplinary care team to serve frail elderly patients in the home, is another model that has demonstrated fewer hospital admissions, shorter lengths of stay, reduction in readmission rates, and reduction in long-term care facility stays.

A viable practice model?

Family physicians also are looking to alternative practice models that offer more flexibility and greater career satisfaction in the face of administrative complexities and expenses of health plans, according to the AAFP.

With that said, remember that office-based practices and centralized facilities opened for many financial and administrative reasons. Much of them had to do with time and efficiency related to insurance reimbursements. So, if you’re considering offering house calls, examine the pros and cons of establishing it as a service mix by conducting a thorough review of the elderly patients in your panel who could benefit from this service. Look at fixed costs to the practice, vehicle expenses, travel time, liability implications of delivering care offsite, potential of injury, and costs or lost revenue from being away from practice versus public and private reimbursement levels.

Samantha Pozner, MD, opened her practice, Springfield Family Practice in New Jersey, in 2000 and began making house calls in 2002 when an elderly patient no longer could make it in to see her.

“She didn’t live that far away from my office. When I needed to see her, I left the house early. I would see her on my way in, and then I was on my way,” Pozner says. “Once you have it in your head you can do that, the opportunities present themselves.”

Over the past 10 years Pozner has seen about 30 patients through home visits. She says her success is based on defining parameters that work for her: she only visits patients who live between her home and office or near where she drops off her children. She adds that she doesn’t carve specific time out for house calls; rather, she fits them in when she can around her office practice.

Andrea Brand, MD, a family physician in Florida, left a traditional office practice for a cash-only house call practice, Dr. Brand at Your Door, in 2004. For 7 years, she handled about 300 patients, starting her business with a $5,000 budget and working out of the trunk of her car. Her patients came via word of mouth.

Although the house call practice had numerous benefits-Brand was her own boss, she made her own schedule, she had more time with patients, and overhead was low-after 7 years, she decided to find a part-time job that allowed her to have a life beyond being available to her patients 24/7.

“It’s not the answer to all of your problems, but it’s a lot of fun and can fit as part of an overall model of healthcare,” Brand says.

The future

Constance F. Row, executive director of the American Academy of Home Care Physicians, says, “Seniors want to age in their homes. They need to be supported in doing that if we’re ever going to solve the cost problem in this country. All we need is for more people to think about it, even though a big barrier is physicians in this generation are not trained in home care. It is something people will have to learn something about.”

Row says that caring for patients in the home ideally will become a routine part of training for all primary care professionals.

“I’m very hopeful this will become a permanent part of the U.S. healthcare system. I feel it must,” Row says, adding that a 3.7% increase in the number of house calls paid by Medicare occurred from 2010 to 2011.

Brent Feorene, president of Colonnade Healthcare Solutions, a Westlake, Ohio-based management consulting firm, says a renewed interest in house calls surfaced in 1999 when Medicare developed codes specific to house calls. Healthcare reform’s fee-for-service push refocused concern on what happens to patients comprehensively. The house call, he says, became a tool targeted at the top 3% to 5% of elderly patients who cannot access the healthcare system in a normal way.

House calls can differentiate a practice, he adds, and make it more attractive by using a different approach to delivering primary care. But he says a learning curve exists.

“You’re not dealing with sore throats,” Feorene says. “These are all frail, elderly individuals with multiple chronic conditions. It requires a sophisticated level of medical management of these patients to help them to live safely and comfortably at home and not have to go to the hospital or to avoid a nursing home.”

On the cusp of change?

Rebecca Conant, MD, is the founding director of the University of California, San Francisco (UCSF), Housecalls program, which has provided in-home primary care to more than 300 frail, homebound elderly patients since 2001. A strong sense exists that home visits are critical to providing care to an overall population of patients, she says.

The Housecalls program is operated as a nonprofit organization, supported by local foundations and donors. About 80% of patients are poverty level or low income.  The program began with a philanthropic gift to teach medical students about home health, but it quickly became clear that a whole cohort of patients was not receiving ongoing primary medical care because they were homebound and unable to travel to clinics, Conant explains.

“Their only interactions were through emergency [departments] and hospitals when they would hit a crisis,” she says, adding that the original donor agreed to broaden the program from a strictly teaching program to an ongoing medical care provider program through UCSF faculty.

The capability of providing care in the home has increased dramatically over the past 10 to 15 years through the portability of electronic health records, equipment, and supplies, she adds.

“We’re just seeing the cusp of this, with the focus on chronic care management and chronic illness, with medical homes pushing that back out into the community,” Conant says. “If we go upstream to keep people out of hospitals and emergency [departments], they do better, have better outcomes, and it’s less cost overall to the system.”

A study published in the November/December 2012 issue of the Journal of the American Board of Family Medicine reported that the number of house calls made to Medicare beneficiaries more than doubled in recent years, although the number of physicians making the calls decreased. 

One of the study co-authors, Steven H. Landers, MD, MPH, president and chief executive officer of VNA Health Group in New Jersey, says home care medicine is becoming a specialty, of sorts, within primary care. Increased payments from Medicare, an aging population, consumer preference for all types of care at home, mobile technology, and a new focus on PCMHs and ACOs is influencing the resurgence of the house call as a viable healthcare delivery model for frail, homebound elderly patients.

“I think it will follow a lot of trends we see with the hospitalist model and the skilled nursing facility model,” Landers says. “More and more of those physicians are entirely focused on that particular venue.”

Community providers, home health agencies, hospice care workers, home health aides, and personal care workers all provide services that can augment a house call practice. Landers says that a need exists for more physicians support and leadership among these community-based agencies, and establishing relationships with those entities can help patients stay in their homes longer.

What to pack in that black bag

• bandage scissors,

• cell phone,

• cerumen spoons,

• gauze/tape/packing,

• gloves (sterile and nonsterile),

• glucometer,

• lubricant,

• maps or GPS,

• otoscope/ophthalmoscope,

• phlebotomy equipment,

• sharps container,

• sphygmomanometer (variety of sizes),

• sterile specimen cups,

• stethoscope,

• tape measure,

• thermometer,

• tongue depressors, and

• tuning fork.

Optional equipment

• computer (portable printer and fax, wireless card, electronic health record),

• dictaphone,

• externally worn hearing amplifier,

• personal digital assistant,

• portable electrocardiograph,

• pulse oximeter, and

• vaccines.

Documentation

• advance packet (names, phone numbers, policies, scope of services, questionnaires and patient forms),

• assessment tools (mini-mental state examination, geriatric depression scale, screen for caregiver burden),

• billing documentation,

• business cards/appointment cards,

• patient record,

• phonebook of essential community numbers and services, and

• prescription pad.

Medicare definition of homebound

To be eligible for home health services, a Medicare beneficiary must:

• need intermittent skilled nursing care, or physical, speech, or occupational therapy;

• be confined to the home (normal inability to leave; requires considerable and taxing effort to leave; requires supportive devices such as canes, wheelchairs, and walkers to leave; requires special transportation to leave; requires help from another person to leave; medical contraindication for leaving the home);

• be under a plan of care established and periodically reviewed by a physician; or

• be receiving the services from a Medicare-participating home health agency.