The old-time practice of doctors making house calls to see patients with acute illnesses is making a comeback for a different purpose: to provide on-going primary care to certain patients. Home-based primary care programs, many of which are run by academic medical centers, are gaining increasing interest nationwide as a way to bring comprehensive care to patients who are homebound with severe chronic conditions.
A study published in JAMA Internal Medicine in 2015 showed that about 2 million Medicare patients age 65 or older were homebound in 2011. Many homebound patients live with severe chronic conditions and functional impairments—from dementia to heart disease to movement disorders—that make it difficult or impossible to visit a doctor.
“[The number of homebound patients] is larger than our nursing home population,” says study lead author Katherine Ornstein, PhD, MPH, an assistant professor of geriatrics and palliative medicine, and an epidemiologist, at the Icahn School of Medicine at Mount Sinai in New York. An additional 1 million patients are home-limited, going out sometimes but only with assistance, Ornstein adds.
“The experience of seeing patients at home is substantially different than in a clinical setting. And seeing that world is really eye-opening.”
Katherine Ornstein, PhD, MPH
Icahn School of Medicine
The repercussions? Homebound patients often delay going to a doctor’s office until their conditions have worsened. They use ambulances and emergency rooms to access basic primary care and have high rates of hospitalization and hospital readmission. These factors make them among the costliest patients.
To better treat them, an innovative care-delivery approach—home-based primary care—is gaining interest nationwide. When consistent, comprehensive primary care is provided to homebound patients where they live, quality improves and health care costs are lowered, according to a study of the Department of Veterans Affairs Home Based Primary Care program. Right now, only about 12% of homebound patients receive primary care in their homes, says Ornstein.
Some teaching hospitals and medical schools are already involved in bringing such care to more of the homebound. Institutions are running home-based primary care services, have taken part in a Medicare demonstration project, and are expanding learning to include training in house call medicine. More are likely to follow as the concept gains broader acceptance, payment structures shift from fee-for-service to value-based models such as accountable care organizations (ACOs), and workforce shortages are addressed.
“I think there’s a lot of opportunity and interest in doing this,” says Keith Horvath, MD, AAMC senior director of clinical transformation. “Health systems are now seeing that maybe the best way to improve outcomes and control costs is by bringing care to the patient.”
Looking at results
Home-based primary care focuses on the whole patient and provides direct, ongoing care for medical, emotional, and social needs, and diagnostic testing. Home visits identify problems that might not be uncovered during an office visit—such as patients using the wrong medicines, fall risks in the home, or pets being around someone who has severe breathing problems.
“The important thing is getting good medical staff into the home, where they see the patient, the family, and the environment,” says K. Eric De Jonge, MD, executive director and cofounder of the MedStar House Call Program at MedStar Health and president of the American Academy of Home Care Medicine.
There are a variety of home-based practice models. Each patient in the MedStar program has a team with a physician plus nurse practitioners, physician assistants, social workers, and others. Doctors conduct the initial home visit, do follow-up visits with very sick or complex patients, and care for the homebound if they are in the hospital.
The MedStar practice is one of 17 home-based primary care programs that participated in Independence at Home (IAH), a five-year Medicare demonstration project. Other house call programs taking part included Boston Medical Center, Christiana Care Health Services, University of Pennsylvania Health System, and Virginia Commonwealth University.
IAH was designed to see if home-based primary care could produce good clinical results and cost savings. Teams coordinated all medical and social services for patients, with 24/7 access to care, visits within 48 hours of hospital or emergency room discharge, and a mobile electronic health record.
Programs were judged on six quality metrics. Those that reduced costs to Medicare by more than 5% could keep 80% of the savings. The project ended Sept. 30, 2017.
Results from IAH’s first two years show the teams served more than 10,000 homebound patients and saved $33 million, with $16 million going to Medicare and nearly $17 million to nine programs that exceeded the minimum savings. All programs taking part in IAH reduced emergency room visits, hospitalizations, and 30-day readmissions for homebound patients.
A Senate bill (S. 464) would convert IAH from a demonstration project to a permanent Medicare program. “If it passes, that would bring significant dollars into the field to support this wonderful care,” says Thomas Cornwell, MD, CEO, Home Centered Care Institute (HCCI), a Schaumburg, Ill., organization that seeks to increase access to home-based primary care for all patients in need.
Educating for home-based primary care
In addition to having insurers pay for such services, the success of house call medicine will depend on attracting and training a larger workforce. A 2016 Health Affairs study found that almost half of 1.7 million home visits were conducted by only 9% of 5,000 primary care providers. In some regions, especially rural ones, access to home-based primary care is limited or nonexistent due to a shortage of trained providers.
“It’s actually one of the most fun primary care jobs because you work with a team out in the community. You’re not sitting in an office seeing 20 to 25 patients all day.”
K. Eric De Jonge, MD
Some programs are training for the future. Mount Sinai Visiting Doctors teaches house call medicine to a wide range of learners, from third-year medical students, residents, and fellows to nurse practitioner trainees and social work interns. A survey conducted with the program’s medical learners at the end of their rotations showed that nearly all believed caring for the homebound is valuable and that learning to care for the elderly was an important part of their education.
“The experience of seeing patients at home is substantially different than in a clinical setting,” says Ornstein. “And seeing that world is really eye-opening.”
It’s a world that HCCI’s Cornwell knows well. He’s conducted about 33,000 home visits as a family physician. On one day, he saw nine homebound patients who, between them, had 134 significant diagnoses. Medical education, he says, provides very little teaching about caring for patients with multiple chronic conditions, where to find the resources they need, and how to get social services at home.
To better equip physicians and others to start providing home-based primary care as soon as possible, HCCI held two-day skills training sessions in 2017 and is planning more sessions and online training for 2018. The programs are held at academic medical centers, including the University of Arizona, Cleveland Clinic, and University of California, San Francisco. HCCI also plans to develop a brief curriculum to familiarize medical students with the field and expanded training for residents.
If IAH becomes a Medicare-approved program, more teaching hospitals will be encouraged to establish house call medicine programs, says De Jonge. Medical schools could then provide related education for students. “You can’t teach them about home-based primary care, or hook them on it as a career, if your teaching hospital doesn’t have a program,” he says.
“It’s actually one of the most fun primary care jobs because you work with a team out in the community,” De Jonge adds. “You’re not sitting in an office seeing 20 to 25 patients all day.”