Medicine goes mobile: The house call returns

[Guest]

Good news for EMS providers!!!!!!!!!!

Medicine goes mobile: The house call returns

By Rita Rubin, USA TODAY

Tue Apr 4, 7:09 AM ET

When David Perryman has a doctor's appointment, his tiny kitchen serves as both waiting room and examining room.

Perryman, 61, has been on disability for 12 years. He uses a walker to get around his one-bedroom apartment, where he lives alone. His breathing is labored because he has emphysema and, on top of that, severe curvature of the spine that prevents his lungs from fully expanding. His doctor's office is only a mile away, but it might as well be a thousand.

So about once a month, internist Richard Diamond comes to him.

Perryman is one of a small but growing number of patients across the USA whose doctors make house calls. Often these patients have limited mobility or failing minds and would otherwise never see a doctor unless taken by ambulance to the emergency room. Others could travel without much difficulty but prefer the convenience of house calls when available.

The number of Medicare beneficiaries receiving medical care at home has been rising since 1998, when the federal program increased payments for house calls. In 2004, Medicare paid for about 2 million home visits, still just under 1% of outpatient visits for medical evaluation and management, according to research published in November in The Journal of the American Medical Association.

Medicare also has launched a three-year pilot project in which 15,000 chronically ill elderly patients in California, Texas and Florida can receive in-home care 24/7 from board-certified physicians. The patients, all of whom have their doctors' cellphone numbers, pay nothing beyond their traditional fee-for-service Medicare.

The project aims to keep older patients out of the hospital, the most costly and traumatic venue for health care. "If they don't have access to care, they become the ER frequent fliers," says Constance Row, executive director of the American Academy of Home Care Physicians. Row says some of the biggest proponents of house calls are emergency-medicine doctors who have seen the need firsthand.

With the U.S. population aging, the supply of doctors willing to do house calls falls far short of the demand, Row says. That reflects a bigger problem, she says: a shortage of primary-care doctors, let alone geriatricians, who specialize in providing primary care to elderly patients. Most doctors prefer more lucrative specialties, Row says.

Her office receives calls daily from patients or families desperate to find a doctor who will come to their home. "I cheer every time we get one person" to begin making house calls, says Row, a former hospital CEO who visits medical schools to encourage doctors-to-be to consider home care. "There are some who see this as a calling."

Doctors are enthusiastic

The term "house calls" evokes a simpler time, long before anyone ever heard of managed care or even Marcus Welby, the solicitous TV doctor who flew to his patients' sides more than three decades ago. Doctors who only make house calls wax enthusiastic about escaping the financial pressure to see as many patients as possible to cover their overhead.

"What we were taught in medical school - how it's important to make a relationship with a patient - that's all falling by the wayside because of the numbers crunch," says family practice doctor Joseph De Danti, who closed his office in York, Pa., last fall and now does only house calls. "I just wanted to make it more personalized."

De Santi, who doesn't accept insurance, charges $99 to $149 a house call. Patients who would like to see him on an ongoing basis can prepay for four visits at $99 each, and he'll throw in a free first visit, for a total of five for $396.

"I certainly wouldn't mind being a little bit busier," he says. "Part of it is getting the word out to people: There is an alternative to waiting for hours at the emergency room."

Family practice doctor Robert Shannon, 52, made house calls even when he had 12 employees and 4,000 patients in his office-based practice in Jonesville, a small town in southern Michigan. When his children left home, he and his wife decided to move 250 miles north, near her parents. About 2½ years ago, he sold his practice and opened Country Doctor House Calls in Bear Lake, Mich.

"Before we moved up here, we called a veterinarian and said, 'What do you charge?' Called a plumber: 'What do you charge?' " says Shannon, who'll stitch up a cut and give a tetanus shot for $100.

Shannon figures he needs to make five house calls a day to break even. Last year, he made 1,562 to patients of all ages, not all homebound. Some are parents who would rather not take a sick child to a doctor's office. Others are young adults who want to avoid an expensive emergency room visit for stitches.

"We're not making a lot of money, but we're not going broke," Shannon says. He works Tuesday through Saturday so he and his wife can hit the nearby ski slopes Mondays when crowds are smaller.

By limiting one's practice to house calls, "you have fewer patients and more time to spend with them," says geriatrician David Phelps of Olathe, Kan., who gave up his office practice two years ago.

But Phelps and his colleagues consider themselves innovators, not anachronisms. Their proverbial black bag likely holds a laptop computer along with more traditional medical instruments. Phelps makes rounds with two rolling suitcases' worth of equipment. His cellphone speed dial holds the number for a company that X-rays patients in their homes.

"Technologically, we can do so many more things in the home than we were able to do," says gerontologist Bonnie Kantor of Ohio State University, where all medical students make house calls during their training in chronic care.

Steven Landers wasn't even born when Marcus Welby, M.D., premiered in 1969. Landers, 30, completed his residency in family medicine last June at University Hospitals of Cleveland, an affiliate of Case Western Reserve University.

Landers began making house calls as a resident. "When I thought about becoming a doctor, what I really was excited about was helping sick people who are in need," he says. As he was finishing his residency, his department chair was setting up a primary-care program for elderly homebound patients. Landers eagerly signed up.

Now he makes house calls three or four half-days a week, seeing four or five patients a day. The rest of his time is spent teaching, seeing hospitalized patients and overseeing the nurse practitioner who sometimes provides follow-up care after he assesses a homebound patient's needs. "I've totally fallen in love with it," Landers says. "I can't imagine doing anything different."

He says he learns far more about patients than if he saw them in an office. He asks to check cupboards to make sure those with high blood pressure are sticking to a low-sodium diet. He can look in their medicine cabinets to see whether they're remembering to take their pills. And he gets to meet relatives and neighbors he never otherwise would.

Landers tells of a patient with chronic heart failure and mild dementia: "When I was in the home, I met her husband, who is a wonderfully interested and dedicated caregiver." Before Case Western began offering house calls, the man never saw his wife's doctor. He would drop her off in front of the office building and circle the block until she came out, because he couldn't afford to pay for parking.

By caring for patients in their home, "you see the patient as a person, rather than as a disease," says Arik Olson, 33, medical director of New York Downtown Hospital's house calls program. "I think sometimes in medicine we forget the patient's a person."

Olson began making house calls as a student at the Medical College of Virginia. "I think the foundation was laid because I had a close relationship with my grandmother," he says. "My grandmother lived to be 95. She was pretty sick, and she was homebound."

'Something you should do'

Richard Diamond's general practitioner father also made house calls. "I always thought it was something you should do," says Diamond, 55. About five years ago, he says, he persuaded Baltimore's Union Memorial Hospital, his employer, to add house calls to its geriatric-medicine program.

Diamond usually makes a couple of house calls a day after a full day at the office. On weekends, he schedules home visits with new patients, who take longer to assess. He carries a traditional doctor's bag, the leather softened by age.

Perryman is Diamond's first house call on an unseasonably warm March afternoon. Perryman has lived more than 40 years on the first floor of a row house in Baltimore's Hampden neighborhood, a former mill town that's now home to funky shops and cafes. But his Hampden is limited to the street corner he can see from his kitchen, the first room inside his front door.

"What takes you two minutes to do takes me an hour," says the stocky, genial man who had worked at a plant that made air filters. "My neighbors help me out."

Diamond listens to his heart and lungs with a stethoscope, checks the pulse in his ankles and advises him to double his diuretic dose when they're particularly swollen.

Then the doctor chides his patient for smoking. Perryman hangs his head. "I've tried. I just can't quit smoking. It's boring sitting here."

Diamond's next two patients live in row houses two doors apart, but they'll never pass on the street.

Virginia Pack, 85, spends her days and nights on a hospital bed in her living room. She went into cardiac arrest a year ago and suffered brain damage that left her unable to speak. She receives nourishment through a feeding tube and oxygen through a tracheotomy tube.

Pack's daughter, Lee Sullivan, 57, is devoted to caring for her at home in the neighborhood where she has lived her entire life. When Pack dozes, Sullivan sleeps on the couch next to her. Sullivan says she can't imagine leaving Pack's care to strangers in a nursing home.

"That's my mother," says Sullivan, who calls Pack "a living miracle. ... Who wouldn't do it?"

Diamond responds quietly: "A lot of people."

Sullivan's neighbor, Shirley Lovill, 57, cares for her 89-year-old father, Joseph Shaffer, who lies on a bed in what once was the home's dining room. Lovill calls Diamond's visits "a godsend." Circulatory disease led to the amputation of her father's left leg several years ago, and it's difficult to line up a wheelchair van to take him to a doctor's office.

A framed photo montage above his bed shows a handsome, smiling Shaffer in his World War II uniform. His great-grandsons, who also live in the house, watch TV in the next room.

"You've got the blood pressure of a teenager," Diamond tells Shaffer as he removes the cuff. "That's what keeps you going."

That and three cans a day of "juice," otherwise known as Ensure, the nutritional supplement drink. Sometimes, though, Shaffer refuses the drink, Lovill tells Diamond, who prescribes an appetite stimulant. If Shaffer doesn't take in enough calories, his pressure sores won't heal properly.

Back in his car, Diamond reflects on his house-call "hobby."

"It's very satisfying. That's why I do it. These people are very appreciative. You're making a difference."

Epilogue

Joseph Shaffer died Friday night. "I visited him Thur AM before office hours," Diamond wrote Saturday in an e-mail. "He appeared to be near terminal with pneumonia." Shaffer had told his daughter that he did not want to go to the hospital, and, after a long talk with Diamond, Lovill decided to honor her father's request.

Diamond arranged for a hospice to provide comfort for Shaffer and his family, and he died "at home, peacefully, without pain or distress. As we say in the trade, 'It was a good death.' " Diamond says he assured Lovill that, thanks to her exceptional care, her father had probably lived years longer than he would have in a nursing home.

Wrote Diamond: "This is the mojo that keeps me and other house-call physicians going."

Edited April 5, 2006 by EM2FD

[Guest]

I remember a few years back that "House calls were coming back". Saves everyone money (patient to Insurance Company). When I worked EMS in Cote Saint Luc, Montreal, WHenever we weren't getting slammed with calls, we were doing welfare checks on our known elderly/sick patients. This program trully benefits EMS, in the fact that it will reduce the volume of "nusciance calls" we get. We need to get on the band wagon with this.