Bernabe Bernades, 79, is mostly confined to a wheelchair after suffering a heart attack and a stroke. He lives alone in a residential hotel near downtown San Francisco. Getting from home to a clinic requires lots of coordination and effort, said his doctor, Natalie Young, MD. So she goes to him.
Young usually finds Bernades alone, watching a black-and-white western on TV. His one-room apartment is full but well organized, with shelves and cabinets along every wall.
The doctor sits on a low stool next to his wheelchair, a laptop balanced precariously on her knees. "How are your legs? Can I look at them?" she asks before rolling up his sweatpants to expose his lower limbs.
He tells her he coughs whenever he eats or drinks, and he still needs to go down the hall to the shared bathroom several times a night, despite a cocktail of prescription drugs aimed at bringing that under control.
"Sometimes I recommend seeing a urologist who's an expert on that sort of thing," Young responds. "Would you like that?" He nods. Then she offers him a flu shot and proposes a visit from a speech therapist, who might be able to help with his problems coughing and swallowing.
Bernades is a perfect example of what geriatricians see every day, Young said — older patients with multiple chronic disabilities and social challenges. They may be living alone, struggling to manage the activities of daily living.
"You are not one to complain or make a big fuss," she reassures him. "You went to a rehab facility after your hospitalization. Would you ever think about going back?"
"No," he answers quickly, shaking his head. "I don't want that. I'd rather stay here and take care of myself."
Young finishes the visit and then leaves. "I worry about him," she said, after closing the door.
Visiting the Homebound
Physician home visits are a growing trend in healthcare, driven largely by the aging population of the United States. Various programs across the country provide primary care services for homebound seniors, such as the UCSF Housecalls Program, which linked Bernades with Young.
The program is staffed by nine physicians, three nurse practitioners (NPs), two practice coordinators, and two nurse case managers. It covers the entire city of San Francisco, including the notoriously dangerous Tenderloin district, where Bernades lives.
"For us, safety comes first," Young said. "If you feel unsafe, you don't go to the home. When I make visits, I take careful stock of the patient's physical environment, including the neighborhood. But I've never felt that a neighborhood made me too uncomfortable to proceed with a visit, although I don't go out late at night.
"Much of what we do involves the psychosocial factors that influence health," she said, adding, "I could probably use more training in substance abuse and mental health issues."
21st Century House Calls
Although home care may be a growing trend, only 12% of an estimated 2 million or more homebound patients receive such care, said Thomas Cornwell, MD, a family physician in Wheaton, Illinois, and founder of Northwestern Medicine HomeCare Physicians.
Dr Thomas Cornwell visiting an elderly homebound woman.
That leaves the vast majority of homebound patients with no access to timely routine medical care. An acute problem that could be taken care of in a quick office visit can become a 911 call and a costly ambulance trip to the emergency department.
Historically, Cornwell said, home visits were much more common, although medically, the care that was provided was less intense than it currently is. In 1930, 40% of all patient-physician encounters took place in the patient's home. The proportion shrank to 10% by 1950, and then to 0.5% during the next few decades. Home visits began making a comeback in the late 1990s, when per-visit payments increased.
But these aren't your grandpa's house calls — quick visits to sick neighbors in a small town. Today, home visits are made to the most medically complex and costly patients. Traveling to patients' homes adds windshield time, parking challenges, and congested traffic to the agenda of a standard medical office visit and requires bringing essential equipment and supplies. But advocates say these barriers are not insurmountable and that home visits by primary care providers fulfill a critical need.
Some providers also find this work more meaningful and personally satisfying than the brief encounters with patients that typically occur in the office setting, Cornwell said. "Even if it costs more money, it is still such incredible care," he said.
Risk and Reward
Fee-for-service reimbursement, which rewards volume over value, generally does not adequately cover the costs of home primary care visits. Some house call programs need supplemental sources of revenue. "Philanthropy has been a big part of our group's growth," Cornwell acknowledged. He expressed concern that such reliance may not be sustainable in the long term.
Payment levels have improved in recent years, but the real opportunity for growth lies in the system's gradual evolution to value-based care and risk-sharing models. "That's not happening as quickly as I might wish, but it's a quantum leap from even 4 years ago," he said. Health plans, accountable care organizations, and healthcare systems that have accepted financial risk for managing patient populations efficiently while avoiding unnecessary hospitalizations or emergency department visits are more likely to find that a service such as this one is a good fit.
Value-based care creates momentum for home-based primary care (HBPC) when health plans opt to incentivize primary care providers for patient-centered outcomes, sadi Michael Le, MD, chief medical officer of Landmark Health, a multidisciplinary medical group in Huntington Beach, California. "The move away from fee-for-service has been a staged process, but I think we are at an inflection point where there will be big uptake from insurers and from Medicare — which will create more sustainability for our field," he said.
As a hospitalist, Le observed that many of the patients he discharged ended up back in the hospital. "I thought, why can't we just move beyond bricks and mortar?," he recalled. "So 6 years ago, we decided to build a mobile medical model."
Le wanted to include behavioral health specialists, psychologists, nurse care managers, and dieticians and to provide 24/7 coverage. "We were confident that if we were willing to take risk, we could make a pitch to the health plans to cover our robust interdisciplinary team, saying: If you cover the cost of our program, we'll save you money. As long as we meet their quality metrics, we can split the savings with them.
"When you go into the home, you see hoarding, fall risks, empty refrigerators, all of the patient's pills in a bowl," he continued. "You say: 'Now I understand what's going on with this patient.' "
Today, his home visit program has contracts with 14 health plans in 13 states and covers 100,000 lives under risk sharing. "From a metric standpoint, we see 30% to 40% reductions in hospital admissions, and high patient satisfaction," he said, adding, "For the 5% to 10% of patients who can't leave their homes, we need to come to them."
The House Call Routine
Cornwell made his first medical house call in 1993, when he prevented a hospitalization for a patient who had called his urgent care clinic complaining of abdominal pain. In 1997, Cornwell was asked to establish an HBPC practice (now based at Northwestern in suburban Chicago) for patients who couldn't access healthcare services except by ambulance. He quickly became a full-time house calls doctor. He estimates that he has made 32,000 home visits in the past two decades — 1600 per year, averaging nine visits per day — with the help of a medical assistant who drives from home to home while Cornwell charts in the passenger seat. The medical assistant also helps with drawing blood and reconciling medications.
"When we started, I had one of those brick-sized portable telephones with a long antenna, and portable x-ray equipment in the back of the van," Cornwell said. Now, he provides more high-tech care in the home than many primary care physicians do in their offices, including ECGs and ultrasound using his smartphone, or procedures such as replacing a gastric tube. He also makes referrals to companies that perform x-rays and ECGs in the home.
A typical day starts the evening before, when he reviews the next day's cases in the electronic health record and packs the supplies he'll need. The average age of his patients is 80; one third are older than 85, and most have at least 10 chronic diseases. Those younger than 65 tend to have neuromuscular diseases, cervical spine injuries, traumatic brain injuries, or are dependent on a ventilator.
"Another category where we create immense value is among high utilizers of emergency room care, who may be ambulatory but tend to have mental health or substance abuse issues," he explained.
In 2012, Cornwell founded the Home Centered Care Institute, a nonprofit organization that educates, trains, and mentors other clinicians in how to become successful HBPC providers. He has since cut back on his own home visit schedule so he can spend more time advocating for the concept in Washington, DC, and elsewhere.
The field's professional association, the American Academy of Home Care Medicine, has 950 members. Half are physicians, and one quarter are NPs or physician assistants (PAs), said Executive Director Brent T. Feorene, MBA.
"Home-based primary care is quite real — even though it's still not mainstream," Feorene said. "These patients are frail, with multiple chronic conditions, polypharmacy, and issues with activities of daily living. Getting into the PCP's office is really difficult for them. Lightbulbs are going off for health plans, and the payment models are catching up with the care models."
Who's Making House Calls?
Although most home visits are made by physicians in small, independent practices, some leaders of the movement are located at academic medical centers such as the UCSF Medical Center, Mount Sinai, Johns Hopkins, or the Cleveland Clinic. The latter's Medical Care at Home program includes 2000 patients, which it manages with an interdisciplinary team of providers, said Ethel Smith, MD. "If we can't get a doctor out on short notice, we can send a paramedic to the home to do vital signs and medication reconciliation and then Skype into the office to talk to a doctor."
Smith, a family physician, worked in an office setting for many years before pursuing additional training in geriatrics. She then spent 2 years as a hospice medical director. "The care I give now is so much more thorough," she said. "It's very rewarding; I wouldn't want to go back. But as the population ages, we will need many more physicians to make house calls."
There's also a growing corporate sector for physician house calls, with companies such as Landmark, OptumCare, and Clover Health, a Medicare Advantage plan with 24/7 access by phone or video app. Heal schedules doctor house calls 7 days a week in six California counties.
Doctors Making Housecalls is North Carolina's largest provider of home-based primary care. The Visiting Physicians Association, founded 25 years ago with current operations in 12 states, is a major player in the Centers for Medicare & Medicaid's (CMS's) Independence at Home demonstrations. The federal program started as a pilot program in 2012 and was subsequently renewed. It allows physicians and NPs to spend more time with their patients, perform assessments in the patient's home, and ensure greater accountability for all aspects of the patient's care. It has demonstrated significant improvements in quality of care while reducing overall healthcare costs for homebound elderly patients with complex needs.
Another government demo, Primary Care First, was unveiled by CMS in 2019 as a new value-based payment model for medical practices. It is led by physicians or advanced practitioners who provide care for people with serious illnesses, including those who are homebound. Although the government recently pushed back its planned start date of January 1, 2020, to 2021, advocates believe Primary Care First could still become a major driver of growth. The Veterans Administration's HBPC program offers integrated, patient-centered medical care in the homes of veterans with complex care needs
The Future of Home-Based Primary Care
Primary care providers will be hearing more about HBPC as value-based care models come to the fore. This isn't concierge medicine for the wealthy, nor is it home healthcare, a $38 billion industry that employs nurses, rehabilitation therapists, and other team members to go to patients' homes on a physician's orders, typically for time-limited episodes.
"Licensed home healthcare usually follows a hospitalization and requires a Medicare skilled need, which is met by a licensed provider, whereas home-based primary medical care is longitudinal, for as long as the patient needs it," Cornwell explained.
NPs and PAs are a big part of this trend, said Barb Sutton. Sutton is an NP with Housecall Providers in Portland, Oregan, a health plan for dually eligible, Medicare/Medicaid patients that employs 16 providers who visit the homes of 1600 patients.
Productivity is important, said Brianna Plencner, manager for practice innovation at HCCI, which offers home visit training. But house call providers can't be held to the same metrics or expectations as office-based physicians. Planning is one key to efficiency. To reduce travel time, for example, home visits can sometimes be grouped in settings such as assisted living facilities.
Covering professional costs from fee-for-service billing is hard but not impossible, Plencner said. She noted that HCCI offers classes on advanced coding for home visits and how practices can take advantage of all appropriate billing opportunities. Value-based relationships are the future of this field, she said. But that underscores the need for practices to track outcomes, costs, and metrics to show how they are reducing readmissions and emergency department visits, thereby generating savings for plans as well as increasing patient satisfaction.
San Francisco physician Young agrees. "As our insurance models have changed, health systems are taking on more risk," she said. "The system is starting to recognize all the patients we're responsible for, with their complex comorbidities, who can't get out of their homes to see their doctors. By making home visits, we are reducing unnecessary healthcare utilization."
Larry Beresford is a freelance medical journalist in Oakland, California, with a particular interest in hospice, palliative care, and end-of-life care. He also contributes to the MDedge publication, the Hospitalist Magazine.
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Cite this: House Calls for Homebound Patients: Has Their Time Come? - Medscape - Jan 03, 2020.
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