wsmith4The house-call physician of yesteryear.

 

Yes, Virginia, there still are doctors who make house calls. And the care they offer is far more sophisticated than the treatment Kindly Old Doc could provide in the bygone days when he (back then, the doc was usually a “he”) showed up at a patient’s door with his little black bag.

Though their work may be flying under the public’s radar, today there are approximately 1,000 home-care providers treating hundreds of thousands of patients across the country. But they’re not, like Kindly Old Doc, available to the occasional patient who’s too sick to haul herself out of bed and come to the office. They work as primary-care providers for the homebound—the frail elderly, the chronically ill, and the disabled who cannot leave home to see a doctor, or who can do so only with difficulty.

There’s a great need for this service. “We estimate 4 million frail elderly Americans need primary care brought to their homes because their serious multiple illnesses and disability make them unable to access office-based care,” notes the American Academy of Home Care Medicine, a professional association representing physicians, nurse practitioners, social workers, and others working in the field of home care medicine. “There are many others under 65 who also need this service such as those with chronic diseases such as ALS.”  The 5.2 million Medicare home visits to private homes and assisted living facilities in 2012 reached only 12 percent of those in need of this service, the AAHCM estimates.

These visiting physicians can summon all sorts of diagnostic tools for use in the home—blood work, X rays, ultrasound, EKGs . . . . the doctors work as part of a team (often comprising a doctor, a nurse practitioner, and a social worker) that can minister to more than the immediate medical needs of their patients. (The social worker, for instance, can link the patient with community services like Meals on Wheels, a home health aide, and adult protective services and can order needed home equipment like grab bars and a shower bench.)

The house-call field has flourished since, some 20 years ago, the American Academy succeeded in persuading the Centers for Medicare and Medicaid Services to increase the Medicare reimbursement doctors received for a visit. “Doctors were among the lowest paid on the list of house call providers,” declares Academy president Dr. Mindy Fain, a geriatrician who is co-director of the Arizona Center on Aging at the University of Arizona.  “A nurse’s aide made twice as much for a house call. She made $80 and I think the doctor made $40. The Academy was able to bring reimbursement for a house call to the point where it was reasonable for physicians to make house calls as a part of their practice.

“The population treated by home-care physicians is often invisible,” Dr. Fain points out. “They often can no longer get to the office for a visit because of their frailty and disability. We get used to their going to the ER when a crisis happens—a crisis that could have been prevented; people think that this is how it’s got to be.  For the last three to five years of their lives, their care becomes a series of hospitalizations and emergency room visits. If they can be dragged into a clinic for a 20-minute visit, it’s not the right place or team to meet their complex health care needs. And overwhelmingly they’ll end up dying in an ICU instead of what maybe they would have wanted to see happen if they’d had a chance to discuss that.

“The things the medical team can do in a home visit are remarkable,” she declares. “The team gives the patient and family the time that is needed, and they glean so much information just by walking in the door. In a clinic, you see the patient’s challenges; in the home, you discover her strengths, and you can build on that. There’s nothing like having a conversation over a kitchen table.

“The beauty of this treatment model is that not only is the care better, but there are cost savings. People get what they want where they want it, and the whole system saves a lot of money.” According to the American Academy, “The data shows that house calls can reduce hospitalizations by 60%, and VA data shows a 24% reduction in overall costs.”

 

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  • Susanna Gaertner May 23, 2016 at 4:41 pm

    How wonderful learning that such services still exist, which I would not have know about without your insightful investigation.
    Thanks, Deb, for this informative report….

    Reply