How the Revival of the Doctor House Call May Improve Elder Care
Michael Fleming was flabbergasted by what he found when he visited his aging parents' house.
His father, who had been admitted to the hospital for complications due to chronic heart failure, was sitting at the table, downing a suspicious looking green liquid.
When Fleming—himself a family physician—asked what it was that his father was drinking, "pickle juice," was his mother's frank reply. Apparently, a friend from church had suggested the salty solution after overhearing Fleming's father discuss his ongoing struggle with a chronic cough.
Aside from the unappetizing nature of this particular home remedy, Fleming knew just how dangerous drinking pickle juice could be for someone suffering from heart failure. Just a single 12 ounce glass contained more than twice his father's recommended daily amount of sodium.
Had Fleming not been there, in his parents' home, observing their habits, he might never have known about his dad's new-found affinity for alternative cough cures until it was too late. "How long—three days, four days—before my dad was back in the hospital with heart failure had I not seen my mom serving him the pickled concoction?" he asks.
For Fleming, this example highlights the overwhelming, yet often unrecognized benefits of doctors making house calls to their patients. "We cannot know what we don't know. In the care of the vulnerable elderly this truth never seems to stop surprising me," he says. "That's why home care may be the most important tool in solving out chronic disease management problem."
The fall (and rise) of the house call
For decades, the art of the house call has been in decline. In the early part of the 20th century, it was common practice for doctors to visit their patients' home to conduct health assessments and provide care. Until World War II, about 40 percent of doctors' visits still happened this way.
After the war, a lack of financial incentives for medical professionals to continue making house calls began to drive the majority of clinicians out of patient homes and into centralized offices.
"Despite all of the lip-service to ‘patient-centeredness,' we continue to maintain a highly ‘provider-centric' care model, which is greatly influenced by our ‘provider-centric' payment system," laments Fleming, chief medical officer of Amedisys Home Health and Hospice, and former President of the American Academy of Physicians. "Our system dictates the care we (providers) decide you should have, where we direct you to have it and when it's convenient for us. Obviously, the home is not convenient for us."
The provider-centric payment system to which Fleming refers is the fee-for-service model, which dictates that doctors and other health care providers are to be reimbursed for each individual service (procedure, lab test, office visit) they provide.
Most experts feel that this model incentivizes physicians to perform more services, rather than encouraging them to focus on the overall outcome of these services.
But an ever-aging population and inflating healthcare costs are beginning to alter this paradigm.
One noticeable change is the implementation of the "Independence at Home Demonstration," a home-based primary care pilot program for Medicare beneficiaries that was created by the Affordable Care Act. The goal of this initiative is to determine whether elders who suffer from chronic conditions would receive higher-quality (and more cost-efficient) care if their doctors and nurses came to see them in their own home. The program officially began in 2012 and will continue for at least three years.
Despite the current lack of official legislative incentives, research from the American Board of Family Medicine does indicate that doctors are making house calls to their elderly charges on an increasingly frequent basis. According to an analysis of Medicare part B data, researchers found that the number of home visits made by doctors doubled between 2000 and 2006.
Benefits of house calls for the elderly
The advantages of the in-home doctor visit trend are already beginning to show, particularly in the elderly and those with chronic health conditions.
Numerous studies have concluded that aging adults who receive house calls from their doctors are less likely to be hospitalized or have to go into a nursing home for care. Home visit recipients also tend to experience less cognitive decline and have a lower mortality risk than those who frequently have to visit an outside clinic.
For Fleming, who made house calls to his patients throughout his 29-year medical career, these findings are unsurprising. "Many times it is an extreme burden for older patients to come into an office and it's dangerous for a high-risk patient to come into an environment full of sick people."
Resources for finding a "medical home"
Even though house calls are making a come-back, it may not necessarily be easy to find a doctor willing to venture beyond the walls of their clinic to provide care. Depending on where you live, there may or may not be a provider in your area who offers in-home services for aging adults.
You can check with your local Area Agency on Aging for more information about doctors making house calls in your local area.
Ultimately though, when it comes to managing the medical care that your elderly loved one receives, Fleming says the most important factor to keep in mind is a concept known as the "patient-centered medical home."
A patient-centered medical home isn't a particular person or place; rather it's a method of care which focuses on the patient first. Fleming likens the model to a solar system; with the elderly patient representing the sun, and the members of their comprehensive care team (i.e. primary care physicians, physicians' assistants, nurses, social workers, home care providers, etc.) orbiting around them, similar to planets. Specialists, such as surgeons, oncologists and orthopedists, are comets that may periodically enter a patient's orbit.
Constructing a "medical home" for a loved one is no easy feat, particularly if you are new to caregiving. However, resources such as patient advocates and geriatric care managers are available to help you assemble and manage an effective medical care team.