Who is an Appropriate House Call Patient?

House Call programs generally target patients who have great difficulty leaving their home to get to a physician’s office—usually because they are mobility and/or cognitively impaired. While some patients meet Medicare’s “homebound” requirement, not all do. Most patients are older adults with multiple chronic health conditions, which may be aggravated by frequent acute flare-ups. These patients are also likely to have chronic disabilities and need assistance with basic activities of daily living such as eating or bathing or dressing. Examples of house call patients might include: an older woman who—because of her obesity, arthritis and asthma—is unable to get out of her apartment without extreme difficulty, a man in his 80s whose congestive heart failure and diabetes prohibit him from leaving his apartment to go to the doctor; a woman in her 60s with terminal cancer who wishes to die at home; and an elderly spouse caregiver of an Alzheimer’s patient suffering from depression who is afraid to leave his wife to take care of his own medical needs.  As the residents age, the number who may benefit from housecall services will likely grow. While house call programs may not serve a large portion of senior housing residents, they may help those with the greatest needs and who may take up a great deal of the property staff ’s time.  Referrals to house call programs come from a variety of sources, including home health agencies, hospital discharge planners, other physicians in the community including patients’ own primary care doctors, community agencies like the area agency on aging, retirement communities, families, and hospice.

 

Scene from a Typical House Call Visit:

The thought of getting out of the house for a doctor appointment increases the anxiety of Nancy with every step she takes toward getting ready for the day. Her 65 year old body is being ravaged by the effects of chronic disease (diabetes, heart and kidney disease, arthritis, and obesity). A trip to see one of her 5 doctors can take her most of the day, leaving her feeling exhausted and in pain. Lately, though, some checkups are much easier because now she has a Nurse Practitioner that comes to her home…On a recent visit to Nancy’s apartment, NP Von Heuvel gently touched her legs to check the swelling that had developed over the past few days. She was sitting at her small dining room table between her living and bedroom. They talked about her 25 medications with special attention to drugs that could relieve the swelling and those that could be making it worse. Special consideration was given to communicating with her specialist to assure they participate with her plan of care and a follow up appointment was coordinated as deemed necessary by a conversation between the Physician Specialist and the Nurse Practitioner. NP Von Heuvel can closely monitor Nancy’s dietary intake of salt and fluids while monitoring her weight, all critical indicators of the management of her Congestive Heart Failure.  Then the NP Von Heuvel offers praise and encouragement for the efforts Nancy has taken to adhere to her plan of care.  Nancy smiles and says "I can do better!"  Then NP Von Heuvel leaves.

 

What is a Typical House Call Visit?

A typical house call may involve a first time visit to a new patient from the Nurse Practitioner who pulls up in a car with a little black bag filled with portable medical equipment and supplies. The nurse practitioner will conduct a comprehensive assessment—generally lasting about one hour—of the patient’s health conditions, their living environment and their support system. The nurse practitioner may also bring some portable testing tools with her—possibly including blood testing supplies, a pulse-oximeter,  and a blood pressure cuff—that will allow her to perform some diagnostic tests on the spot. A patient plan of care and medical record will usually be created and sent to our office nurse or assistant who will help arrange appointments with specialist for further testing or make referrals to a home health agency or medical equipment supplier.  Follow-up visits will generally be made as mutually aggreed upon between the patient and nurse practitioner, depending on the patient’s condition.  For Concierge patients, the medical housecall program offers guidance via telephone 24/7 to advise patients who have a medical emergency and determine whether they need to go immediately to the emergency room or are able to wait until the house call nurse practitioner can get to their home. It is important to note, however, that house call programs do not provide true emergency services and are NOT a replacement for calling 911. A house call patient always has the choice of going to the emergency room. Often, appointments can be scheduled within a day or two, and in some cases, the same day for problems that are urgent, but not life threatening.

 

How are House Call Services Reimbursed?

Medicare covers house call visits, whether they are made by a Nurse Practitioner, just like an office-based physician/nurse practitioner visit.  After the annual Medicare deductible is met, Medicare covers 80 percent of each house call visit. The remaining 20 percent is submitted to the patient’s secondary insurer, if he or she has one, to pay the difference. The patient is liable for the amount that is not covered by Medicare or other insurance. In most states, Medicaid will usually cover the remaining 20 percent for those persons who are enrolled in Medicaid. Some HMOs may also pay for medical home care. Not all house call programs accept Medicare, Medicaid or other forms of insurance and one should clarify what forms of payment the provider will accept. 

 

What is a medical house call program?

 An interdisciplinary medical team, typically consisting of a physician medical director and a nurse practitioner, cares for the patient in their home. The Nurse Practitioner will come to the patient’s home

to diagnose the patient’s health problems, design a treatment plan, provide medical care, arrange for any other needed health services and coordinate the patient’s medical care with other health and supportive service providers. The house call nurse practitioner fulfills the role of the patient’s primary care physician or works with the existing primary care physician when the patient is no longer able to get to his or her doctor consistently.  The goal of house call programs is to ensure the best care and quality of life for the patient for as long as possible, in the setting that most patients prefer—their own home. The programs are designed to provide patients a personal relationship with a physician, continuity of care across time and place, and care where it is needed, for as long as it is needed. The house call team will generally provide the following services:  Health assessment, diagnosis, and plan for treatment; Assessment of the home environment for factors that may contribute to health and safety problems; Ongoing medical care; Care management and oversight, both within the patient’s home and across settings, e.g., from home to hospital (using an affiliated hospitalist group) and rehab facility and back home again; Coordination of health services with visiting nurses, medical specialists, hospital staff, hospice services and community agencies to improve the continuity of health and medical care and facilitate hospital admissions; and Support and education to patients and their families so they can make informed health care decisions

 

 

HOUSE CALL PROGRAMS AND SENIOR HOUSING COMMUNITIES CAN WORK TOGETHER... 

 

How Would the Program Help Your Retirement Community?

Picture your residents who are very frail and have multiple chronic health problems. They may be frequently very sick from an acute fl are-up of their diseases. They may have cancer, hypertension, diabetes, arthritis or congestive heart failure, and probably two or more of these conditions. Many are taking multiple prescription medications in addition to over-the-counter drugs. Some are likely to be terminally ill. They may use a wheelchair or walker to get around, if they are able to get around at all. They may have to wait weeks or even months to schedule appointments with their many different physicians each of whom treats one aspect of their overall health problems.  Picture your residents who are anxious about going to the doctor because they fear ending up in a hospital or a nursing home, or who are so stressed about losing their independence they never see a doctor at all. Picture

unscheduled ambulance trips, midnight visits to the ER, your concerns that a few residents are so sick and/or disabled neither you nor their families see how they can continue to live safely in their own apartment.  One potential resource to help your residents address these challenges is a medical house call program, where, on a regular basis, a team of physicians and nurse practitioners or physician assistants come to your most vulnerable residents who have difficulty leaving their apartment. We hope that you will carefully read our guide to medical house calls. Perhaps you will decide that developing linkages between your housing community and these types of programs is another worthwhile step in helping support your residents to age in place.

 

Residents in a number of senior housing properties around the country now enjoy the advantages of having a house call nurse practitioner treat them in their own homes.  The nature of the relationship between senior housing communities and these house call programs varies from place to place.  In some cases, the property manager or service coordinator has almost no contact with the housecall program other than knowing that a nurse practitioner visits residents in the building.  Some properties maintain a referral list of house call programs to provide to residents who request it or to give to residents who they believe could benefit from in home medical care.  Other properties may--with the residents permission-share information about changes in residents' health conditions and/or assist in coordinating personal care and supportive services of medical care provided by the house call staff.

 

  HOUSE CALL PROGRAM BENEFITS:

1. better management of chronic illnesses and decreased emergency room visits

2.  relieved caregiver burden due to transportation needs to get to the doctors office

3.  offers timely visits at home versus a bogged down health care system with waiting lists to see md

 

How do House Calls Differ from Home Health Services?

House call programs are also different from Medicare reimbursed home health services. House call programs provide comprehensive, ongoing medical care and chronic disease management. Medicare home health is primarily intermittent care that provides eligible patients who meet the Medicare definition of “homebound” with skilled nursing care, physical therapy, speech therapy or occupational therapy following an acute illness or medical event.  Medicare home health is usually time limited and it must be focused on treating a specific problem. The treatment must be medically necessary, a plan of care must be certified by a physician and reevaluated every 60 days and there must be evidence that the health condition for which home health services are being provided is improving. Many house call patients receive Medicare home health services while under the care of a house call physician. In fact,

home health agencies are a large referral source to house call programs, because either their patients no longer meet Medicare skilled care requirements or the patient’s medical needs are complex and the patient would benefit from home treatment.

 

 

Research: The Impact of House Calls on Patients

 

A slowly growing body of literature on the impact of medical house call programs concludes that these programs are effective in reducing hospital and emergency room use and improving patient quality of life and well-being.  A 1999 study published in the New England Journal of Medicine found that elderly house call participants reduced their use of hospitals by 65 percent with cost savings of 50 percent over similar patients who received their care through a traditional office-based practice.  A 2004 study of a medical house call program in the mid-west found that the program: (1) improved patients’ medication and health management; (2) helped families feel more informed about the patients’ medical conditions and relieved of the burden of transporting patients to the doctors; (3) reduced hospital and emergency services use; and (4) enabled far more patients to die at home rather than in a hospital. The study also interviewed office-based physicians who expressed relief that they could concentrate on caring for their patient caseload without worrying about managing complex homebound patients over the phone.   Patients and referral sources also expressed high levels of satisfaction with the program.

We hope you give us the opportunity to become a part of your team!