The rise of home visits, or everything old is new again

  | September 15, 2016

Last November, Dameneon Smith, D.P.M., shuttered his podiatry office in Arlington, Virginia, and began making house calls with the help of a cell phone, a car, and a doctor's black bag.
The overhead for running a solo practice had been killing him, he says. Going mobile relieved the financial stress of carrying an office and paying a nurse and an office manager. Now, he treats about 150 patients per month, making house calls, or seeing patients at nursing homes and assistant living facilities.
Home visits, once the stuff of nostalgia, are slowly but steadily becoming more commonplace, especially as a component of geriatric care. And advocates say they're a tactic, not just for happier doctors and patients, but for saving costs in a healthcare system that will soon be flooded with Medicare patients.
According to the American Academy of Home Care Medicine, 11,400 primary care providers — including physicians, nurse practitioners, and physician assistants — made 4.9 million house calls in 2014. Of those providers, 7,800 were doctors, or about 3 percent of the 209,000 active primary care physicians in the United States.
Right now, Medicare pays for the lion's share of house calls, says Thomas Cornwell, M.D., founder of the Home-Centered Care Institute in Schaumburg, Illinois. In 2014, Medicare reported 2.7 million house calls and 3.1 million visits to nursing and assisted living homes — up from 2 million house calls and 2.4 million facility visits five years earlier.
Demographics are driving that increase. Aging baby boomers represent an “exploding home-limited population," says Cornwell, a primary care doctor who has made 32,000 home visits since 1993. The number of patients on Medicare is expected to grow from 54 million older adults in 2015 to 72 million in 10 years.
And some geriatricians say home visits will help keep those costs under control. The Centers for Medicare and Medicaid Services estimates that in 2014, house calls saved the system $25 million nationwide, an average of $3,000 per patient.
That value comes largely from managing patients' care so they spend less time in ambulances and hospitals, says Peter Boling, M.D., a pioneer in helping Medicare develop a fee structure for house calls.
In the past, “if you had a hard time getting out of bed and difficulty getting out of the house, you called an ambulance. The hospital treated you for a non-urgent care. Then you were sent home with a lot of bad advice," says Boling, chair of geriatric medicine at Virginia Commonwealth University, who has been doing home visits since 1982.
Now, medical schools are recognizing the importance of training doctors for home-based visits, says Bruce Kinosian, M.D., a geriatrician and professor at the University of Pennsylvania Medical School. The number of medical schools and residencies that include some training for house calls has increased substantially over the past decade, Kinosian says. And home visit training is often part of the required experience for geriatric fellows.
Home visiting services come in all sizes and shapes, from Smith's mom-and-pop operation to larger, more complex organizations. Henry Tripp, M.D., founded Physicians Home Care in Winston Salem, North Carolina, 10 years ago to do house calls because elderly and chronically ill patients couldn't get to office visits. The practice, now part of a larger network of home care services in the state, covers the eight counties surrounding Winston Salem.
Tripp is the only doctor in the practice, which includes five nurse practitioners and five assistants treating 2,000 patients per year. Providers routinely bring along equipment to conduct x-rays, EKGs, ultrasounds, and vascular studies.
“It's amazing what's available for homes," Tripp says.
And by seeing patients regularly, he says, providers can reduce their medication, manage their chronic illnesses, and avoid unnecessary hospitalizations.
In addition to providing coordinated services, house calls build trust with patients, says K. Eric De Jonge, M.D., incoming president of the American Academy of Home Care Medicine.
Indeed, for many patients, the value of home visits goes beyond direct medical care. Tripp has been making monthly house calls for four years to examine Dorothy Caldwell, 83, who is blind, and her sister, Nancy, 85, who is bedridden from a series of stokes.
“We look forward to these visits," Dorothy Caldwell says. "It's not just an exam. It's a social visit. I feel good when he comes."
Judi Hasson is a writer based in Washington, D.C. Illustration by Daniel Guidera.

The rise of home visits, or everything old is new again