House Calls for the 21st Century

Abstract

Home care is the fastest growing sector of medicine today. It has increased at approximately 20% per year since 1989, and this double-digit growth is expected to continue into the future. In 1990, The Prospective Payment Assessment Commission (DHHS) reported that Medicare expenditures for home healthcare services were $3.5 billion. This increased nearly fivefold, to $16.9 billion, in 1996, and it is expected to have reached $19 billion in 1997.1 Estimates by the Congressional Budget Office estimate the spending for home health services will exceed $30 billion by 2002.2 In 1996, 10% of the Medicare population received in-home services for a total of 280 million visits to 3.8 million beneficiaries.1 Most of the patients (75%) who receive in-home services are 65 years of age or older, with an average age of 70 years, and according to the 1992 National Home and Hospice Care Survey conducted by the National Center for Health Statistics, for every resident in a nursing facility, there are three to four patients of equal debility residing in the community with the assistance of family, friends, and the intermittent services of home healthcare agencies. The comparison between the institutionalized and home-bound populations and the most frail patients in ambulatory practice is especially instructive in exposing the level of involvement of the medical community. The discrepancies between the different settings are striking. In the care of chronically ill patients, it is usually the physician who recommends the frequency of visits for follow-up and monitoring. These are the patients in the office in “fair to poor” health who see their physicians an average of 11 times a year3; in the nursing home, these patient are seen a minimum of 6 times a year, and often 12 or more. The homebound patient is often among the highest users of acute medical services, at great risk for complications, and among the most ethically challenging. Their care demands the highest degree of coordination with other health care providers as well as counseling of family members. Yet in 1994, when 3.1 million Medicare beneficiaries were provided with home care services, only 1.5 million home visits were made by physicians. On average, homebound patients get one visit every 2 years, even though 90% of primary care physicians who answered recent surveys agreed that house calls are important in their management.4 The reason cited most commonly for the low numbers of home visits has been the poor payment for these services. A 1990 AMA telephone survey of a nationally representative sample of 1161 family physicians and internists found that 88% felt that reimbursement was inadequate for physician services in the home.4 The Physician Payment Review Commission stated in their 1994 report to Congress: “First, the homebound represent perhaps one of the most vulnerable Medicare populations. Declines in primary care services to this population might, therefore, merit more attention than would changes in services to other Medicare beneficiaries. Second, home visit services take a considerable amount of physician time but are relatively poorly paid… Advisors to the Commission have suggested that the combination of time and low hourly remuneration along with financial pressures on providers' practices might make home visits a service that is curtailed by providers.” The Office of Inspector General, in their June 1995 report, The Physician's Role in Home Health Care found: “Fourteen percent of physicians report making home visits; most of them say these visits are infrequent and only when absolutely necessary. They add that since Medicare pays so little for a home visit, it is not affordable for them to see patients in their homes.”6 Then there is the lack of medical education. In the past 30 years, medical schools and residency training programs have provided few, if any, home care training experiences. As a result, the majority of physicians in practice today are unaware of the opportunities and “best practice” models for caring for patients in the home. See also p 174 But the times they are a'changin'. Through the persistent efforts of a small committed group, led by the American Academy of Home Care Physicians, the Health Care Financing Administration agreed to reassess the value of physician involvement in the home care arena.7 As of January 1998, Medicare has made extensive revisions to the rules for home visits. These modification are likely to stimulate a profound reconfiguration of the delivery of health care to the chronically ill in this country. The current procedural terminology codes for house calls have been expanded to more closely reflect those used in ambulatory care, and there has been a significantly improved reimbursement structure that makes house calls a financially viable alternative setting for medical practice. Most importantly, the upper level codes allow for the comprehensive assessment of complex patients in the home for both new and established patients. It is now feasible to provide an appropriate level of service for the more seriously ill patients who wish to eschew the hospital and are often too frail to travel to the office. It is also more practicable for acute care services to be brought to the home, avoiding the emergency department and the inevitable hospital admission. It is now conceivable that a growing number of physicians, as recently demonstrated in Chicago and Detroit, will embrace the home as their principle setting for providing care. The second major change is the expansion of nurse practitioner and physician assistant services into the home, without on-site supervision by the physician, and at 85% of the reimbursement.7 This change will allow physicians and mid-level practitioners to work in partnership in the management of the chronically ill, sharing the monitoring visits and using the physician more effectively in unsettled or more complex situations. Nurse practitioners and physician assistants have proven themselves highly capable in the management of frail patients in the institutional setting through such programs as EverCare and Elder Health as well as through the personal experiences of many physicians in a variety of settings. Similarly, this extension of the partnership into home care should lead to a successful augmentation of the array of services provided by larger group practices. In this issue of JAGS, Dr. Fried describes the population of patients most likely to benefit from physician home visits and an academic ambulatory care practice that demonstrates many of the principles needed to incorporate a house call program.8 The patients are typical of the frail and highly impaired older patients followed by home care agencies; 30 to 40% were actively receiving care at the time of the survey. The range of illnesses is also typical of that seen in the clinic and is managed in much the same way, except that the patients were in a setting more conducive to their needs. Many were quite adamant in their refusal to allow hospitalization and obviously tested the acute care capabilities of the practice, which proved very adept at responding to their needs despite the limited resources. One of the three geriatricians took primary responsibilities for the house call program along with the nurse practitioner, who handled the bulk of the visits and telephone calls. They defined a reasonable catchment area to decrease travel time and time away from the practice, and they made both regularly scheduled visits for those patients unable to come to the practice and acute care visits during the day as time permitted. Office procedures established the house call practice as a separate, but highly integrated, part of the overall service. The limitations were driven predominantly by the lack of reimbursement for the nurse practitioner visits and the constraints of an academic affiliation. Nevertheless, the care was clearly highly valued by both the patients and the staff. Much can also be learned from the recognized weaknesses of this program. The network of home care providers and the integration of services across disciplines were not as developed as in other models. Often a home care agency will assign nurses to a larger house call practice and encourage regularly scheduled meetings to facilitate care coordination. Social workers, therapists, and nutritionists from the agency may also participate. The benefits to the agency in improved communication, efficiency in completion of the documentation and orders, and the increase in referrals more than offsets the costs of the personnel. Similar benefits can entice participation by a local pharmacy that delivers medications to the home, a durable medical equipment vendor, and an infusion company. The mutual interests and ability to complement each other's services promote a strong sense of teamsmanship and can result in a more profitable business. A second area that was not fully developed in the program described was the use of newly available, highly portable diagnostic instruments and therapeutic technologies. Advances in miniaturization and automation give the physician on-site access to a wide range of equipment for analyzing blood and urine samples, simple radiography, oximetry, and electrocardiography. Digital processing allows for easy transmission of the results and telecommunication with consultants. Other specialized adjunctive services, which may be available in larger metropolitan areas, include ultrasonography, echocardiography, and Doppler studies. Therapeutic modalities include infusion devices for enteral and parenteral therapies, oxygen delivery devices and ventilators, peritoneal and hemodialysis devices, and specialty support surfaces for wound management. In a well organized program, virtually any service available in a hospital room can be provided in a patient's home. With the changes in Medicare policies and regulations, the opportunities in home care are enormous and the future bright for both the healthcare industry and academia. Visionary leaders in healthcare organizations and physicians' groups recognize that the overwhelming majority of chronically ill patients can be successfully cared for in the home, and nearly everyone would choose care at home to admission to a nursing home. Several studies both here and abroad show that a well organized program of home-centered care for frail older people and vulnerable younger patients can be the most cost-effective, efficient, and most preferred healthcare alternative.9, 10 In addition, the Hartford Foundation has supported a select group of medical schools in the development of home care curricula to educate physicians in training. For those physicians already in practice, the American Academy of Home Care Physicians is providing ongoing education in the administrative and clinical aspects of home care. Many challenges still lay ahead. A decentralized system of health care is highly dependent on information management technologies that are not yet fully standardized or implemented. Increasing numbers of widely disbursed patients will require us to investigate alternative methods of healthcare delivery using less expensive personnel with more focused skills and the training and management strategies to supervise their care.11 However, only with the continuing support of federal, state, and private insurance will the knowledge gained from these experiences lead to the development of a comprehensive spectrum of services in a seamless system of care.