Dr. Eric De Jonge, a geriatrician at Medstar Health in Washington, D.C., is on his way to work—but not at the hospital. After parking his car, he arrives at the front door of a small basement apartment, inside of which he greets his patient: an 82-year-old man bedridden after a stroke. He checks the man’s vitals, asks about his diet and medication, and recommends a regimen of physical therapy.
Yet as De Jonge speaks with the home health aide, who had been helping with cooking, cleaning, and monitoring the patient, and with the patient’s wife, who also serves as his primary caregiver, he learns that the wife is struggling to recover from a recent open-heart surgery. No longer able to drive, she’s been unable to get to the hospital for a post-surgery check-up and has experienced hemorrhaging and other complications.
After treating his patient, De Jonge turns to enroll the wife in the same house-call program that brought him to visit her husband, promising to return for another call in three weeks to make sure she’s recuperating and feels stable and supported.
“She would have lacked medical follow-up because she was ill and dedicated to her husband, and he could have deteriorated if she hadn’t gotten back home [post-surgery],” De Jonge recalls.
Historically, house calls were the only way most people had access to health care. In the early 1900s, doctors provided house calls to patients from the cradle to the grave. But during World War II, as hospitals and medical technology developed, hospitals became the only places where patients could get X-rays and antibiotics—two medical advances that, along with other factors, helped push the United States to the current model.
Now, even though seniors often receive various forms of care in their homes—most often provided by family, as with De Jonge’s patient and his wife—they usually still have to visit a doctor or hospital for primary care.
But new technology has made it once again possible to bring modern medical care into the home. As tech has become smaller and more mobile—back-of-phone EKGs; small, portable refrigerators for vaccines and blood; handheld devices for vision and hearing screenings that can fit in a backpack—house calls are once again feasible. And so house-call programs are on the rise, a development that could be hugely important for patients who have the hardest time getting themselves to the doctor, particularly the disabled, chronically ill, elderly, and other at-risk populations.
Research shows that house calls like De Jonge’s are an excellent way to deliver care, and that health outcomes improve and overall medical costs actually go down through a documented reduction in hospitalizations. But even with doctors like De Jonge, hospitals like MedStar, and Medicare’s support for house calls, the structure of health care in America is getting in the way of making house calls available to all.
In 1995, Mount Sinai hospital was among the first to pilot a program to deliver house calls in New York City, and today the program covers 1,800 patients in Manhattan over the age of 18 who are homebound and who would have difficulty accessing care otherwise. One of the first and largest programs in the country, Mount Sinai has helped put house calls back on the map as an effective way to treat the sickest patients.
“If you have dementia and diabetes and are 85, you may be homebound and unable to access routine primary care. But we could take care of you at home,” says Dr. Linda DeCherrie, clinical director of Mount Sinai at Home, which includes Mount Sinai Visiting Doctors, one of the largest academic, home-based primary-care programs in the country. The Mount Sinai Visiting Doctors program works with community agencies, such as visiting nursing associations and hospice, as well as a network of nurses, social workers, and others, to predominantly treat persons with functional disabilities and multiple health conditions, including dementia, diabetes, hypertension, and depression.
According to DeCherrie, identifying the patient’s goals for care is crucial. For many patients with chronic illness, primary care and palliative care are combined in a house-call model of care, whereas they would be separated in a hospital setting.
“We constantly have to remind each other that we can’t extricate people from their situations. A lot of these diseases or conditions aren’t going to get cured. We’re not going to make the disease go away—it’s about palliative care and the patient’s wishes,” DeCherrie says. That principle holds whether the patient wants help with pain and symptom management, prefers to die naturally at home, or would like to work toward a health goal like visiting their granddaughter’s graduation.
Beyond end-of-life care, in a 2017 study, DeCherrie and her co-authors found better patient outcomes for in-home rather than in-patient hospital treatment. In-home patients reported less hospital re-admission, a shorter length of stay at hospitals, and higher patient ratings of care—not insignificant, given that recent research shows the importance in health outcomes of patients’ ability to build a rapport with their physicians.
Now, a number of hospital groups and small providers are bringing house calls back, with increased support from the Centers for Medicare and Medicaid Services (CMS), the government agency within the Department of Health and Human Services that administers Medicare and Medicaid, and which has begun a push to increase funding for house calls. In 2012, CMS began testing the efficacy of house calls through the Independence at Home demonstration program. The 14 participating house-call programs saved an average of $3,070 per patient, totaling $35 million in savings and reducing Medicare costs by 30 percent, all by reducing unnecessary hospitalizations and improving quality of care and patient satisfaction.
Additional research shows that, when patients have a hard time getting to a doctor and there are limited house call options in their area—most homebound patients live more than 30 miles from a house-call provider—expanding house-call programs greatly improves health and quality of life by supporting more consistent health monitoring and treatment for people with a serious illness or multiple medical conditions, or if they’re near the end of life.
In New York City, Dr. Elaine Lin, medical director of Mount Sinai’s Pediatric Visiting Doctors and Complex Care Program, walks up to the doors of her patients’ homes, sometimes with a social worker, sometimes with a medical trainee, and always with a backpack.
In one of her earliest experiences providing house calls, Lin asked a mom to show her how to administer her child’s inhaler.
“She told me she didn’t want to go to the cabinet to get it because of the cockroaches.” Suddenly, Lin could see that an inhaler alone wasn’t going to treat the child’s asthma.
When she’s in a patient’s home, Lin has developed an understanding of the barriers to care that she hadn’t been able to see from more clinical and formal settings—and she’s motivated to help her patients overcome those barriers.
“Once you know a family, it becomes like you’re visiting your family,” Lin says. “We talk about the medication, and they can physically show us the difficulties with the equipment and point out things that they think are affecting their child’s health”—things like a cockroach infestation that a landlord is unresponsive to, and that can also trigger allergies and asthma in children.
In an expansion of the Mount Sinai program, Lin provides house calls to children with particular needs, such as those with mobility issues or feeding issues, as well as to infants who have recently left the Neonatal Intensive Care Unit. A team composed of multiple providers—three physicians, a nurse, care coordinators, administrative staff, and social workers—provide weighing, developmental, and other medical and psycho-social assessments at home for these children.
According to Lin, the program has been successful in reducing inpatient hospitalizations and emergency room visits, decreasing the length of hospital stays, and coordinating discharge and rehabilitation because of its multidisciplinary approach to care, as well as the experience of being at home with patients’ families, and having a health-care provider who knows you and can help plan for an emergency.
While house calls are linked to improved outcomes, both in terms of patient satisfaction and reducing the costs of care, they aren’t likely to be available nationwide without major structural reforms to health-care financing—and without more widely available training in home care. In primary care, one of the major areas where house calls could help, the challenge for care providers is how to make house calls financially viable.
Many of the programs currently in use are funded through Medicare and Medicaid, but until recently, according to Thomas Cornwell of the Home-Center Care Institute, the reimbursement rates were too low to make house calls financially sustainable. Working outside of a large hospital system like MedStar or Mount Sinai, or outside those two funding structures, can be tough.
Health-care practitioners are currently paid based on the number of services they provide (or patients they see)—what’s called a “fee-for-service” model. Because house-call providers aren’t able to see as many patients as they would in a doctor’s office or hospital—De Jonge spent more than an hour checking on the octogenarian housebound husband and wife—they’ve historically struggled to make ends meet. When medicine is structured as a fee-for service model, doctors and hospitals aren’t incentivized to spend more time coordinating care, or to take the extra time a house call requires. But if, as in the case of MedStar or Mount Sinai, the system incentivizes doctors and hospitals to spend extra time in the home and provide care and improve outcomes, it’s worth it.
Still, for smaller providers dependent on reimbursement rates from Medicare and Medicaid, providing house calls hasn’t historically been financially sustainable. Tammy Browning, a physician assistant in Indiana, opened her own house-call practice because she was passionate about helping people with limited mobility meet their goals and objectives of care. Until recently, when Medicare raised reimbursement rates, it was an open question whether she’d be able to stay in business. Browning believes the house-call model could be beneficial for other at-risk populations, such as children and adults with serious and chronic health conditions or disabilities. But unlike with people over 65 who qualify for Medicare, there’s no payment source for non-elderly services.
Since the 1990s, the American Academy of Home Care Medicine has lobbied to increase reimbursements for a wider range of activities, such as coordinating patient care and taking phone calls, De Jonge says. A wide range of public-health groups, such as the American Medical Association, as well as the AARP, are now also lobbying Congress to make the Independence at Home program permanent and more widely available.
While estimates vary, only about 100,000 of the two to four million bed-bound patients in America currently have access to house calls, De Jonge says.
This could change, if slowly, as the health-care system continues to move toward so-called “value-based care.” Instead of paying health-care providers based on the number of services provided, a “value-based” system instead rewards health-care providers based on how well they improve health-care outcomes.
On April 22nd of this year, CMS announced a new payment model, Primary Cares Initiative, in support of greater value-based primary care, which would be a step in that direction.
According to DeCherrie, working with a patient to provide the care they want and need is an important part of improving the quality of care. It could also save on health-care costs overall, particularly by providing preventative care and reducing unnecessary hospitalization.
Lin says value-based care is a paradigm shift that could redefine what care looks like and where it is provided. And for more and more people, that could mean receiving care at home.
The reporting for this piece was made possible by MemoryWell News for the Ages and New America.
