The yesteryear image of a doctor carrying a black bag into someone’s home is returning to many communities around the country as physicians are once again making house calls. The old-fashioned black bag is now a little larger and contains more “stuff”. Sometimes the doctor even arrives in a van full of medical supplies and special testing equipment. Whether it is with a bag or in a van is not as important as the qualified health care professional that comes with it – the doctor, nurse practitioner or physician assistant.
Benefits of Home Physician Care
Physicians who make house calls perform a significant service that is meaningful to the whole of health care… the care receiver, the caregiver and family, other health professionals and the health care system. Doctors’ home visits are particularly helpful when the care receiver has difficulty in traveling to a doctor’s office. This may be because of being bed-bound, frailty or having difficulty walking and/or going up and down steps. The benefits of home physician care include:
- Convenience – no travel time; waiting time is in the comfort of home
- Comprehensive care – including taking an active approach to receiving help and possibly preventing an emergency room visit or hospitalization while allowing the physician to learn about the home environment and available resources for future planning
- Contamination free – no exposure to the germs of others in a busy waiting room or doctor’s office
- Cost effective – reimbursed by Medicare and many private insurance companies; no travel costs when non-emergency transportation is required
- Caregiver health needs – can be taken care of during the same house call
Home Care Visits Can Prevent Stories Like These
Betty F. of Delray Beach, FL is a single working woman. She devotes her time, while not at her job, to caring for her mother. Her mother, now bed-bound from a stroke, takes, among many other medications, “blood-thinners”. It was tough for Betty to get her mother to the doctor’s office for routine check ups. Money was tight. Stretcher transportation to and from the doctor’s office was expensive. The ordeal exhausted everyone. Betty had to arrange coverage at work in order to take time off; time that was unpaid. It just wasn’t easy. And, since her mother was feeling only a little weaker, it seemed okay to put off scheduling an appointment.
Finally the day to go visit the doctor arrived. Everything seemed to come together. It was all going as well as could be expected for someone on a stretcher and her caregiver. Then the doctor announced that Betty’s mother had to go right to the hospital for emergency blood transfusions! Without proper check ups, the blood-thinners had caused a slow blood loss. Luckily Betty’s mother received help before a much more serious complication occurred.
Stan of Detroit, MI recently retired at 74. He and Elizabeth have been married for 42 years. For the past couple of years, she refused to leave the house. Their only daughter just completed a Holiday visit. During this time she became very concerned about her mother. She discovered that her mom was now very thin, had a bad cough and spent her day on the sofa watching television. Her dad cooked as best he could; sometimes food was delivered. He kept their small house neat. In spite of her family’s pleas, Elizabeth absolutely would not go to the doctor.
Finally a nurse friend recommended a doctor’s house call service. Reluctantly, Elizabeth agreed since she didn’t have to leave home. The doctor visited. A home chest x-ray showed that Elizabeth had emphysema. She began proper treatment, including nutritional support. Today, thanks to physician home care and proper treatment, Stan and Elizabeth continue their lives and are able to more fully enjoy their time at home together.
More Home Care Doctors on the Way
Unfortunately these are not unusual stories says Constance Row, Executive Director of the American Academy of Home Care Physicians (AAHCP). She points out that a 1997 American Medical Association (AMA) study shows that only 1% of homebound persons receives adequate primary care! The good news is that AAHCP also reports that more and more doctors are making house calls. Medicare received about 1.5 million requests for physician house call payments in 1998, the largest number since its inception.
One of the reasons more doctors are making house calls these days is that as of January 1, 1998, Medicare reimbursement for physician home visits increased. The payment of $69.60 in 1991 increased to $139.04 in 1998. There are additional annual increases projected through 2002 at which time reimbursement will be $203. This payment allocation is for the most complex type of visit. As of this writing, Medicare does not reimburse for physician travel time, only for time spent in the home. Managed care and private insurance coverage varies but many companies now recognize the value of this service and will cover the charges. As with other medical expenses, it is wise to check with the carrier first.
The changes in Medicare are largely due to the efforts of C. Gresham Bayne, M.D. of San Diego, CA, one of the pioneers in the return of doctors to making house calls. He is Chairman of The Call Doctor Company. One of the services his company provides includes response to urgent care patient needs thus further avoiding emergency room visits and/or hospitalizations.
Another reason that physician house calls are increasing is that some doctors are finding they really enjoy the holistic experience of house calls. Private companies, such as Visiting Physicians Associates (VPA) of Southfield, Michigan hires Board Certified physicians full time. Most of them become their patient?s primary care doctor. The philosophy of VPA is to allow the doctor to do what he or she does best; practice medicine. The company handles the business aspects of home physician care. The doctors evaluate the patient as a whole. They routinely complete a Lifestyle Assessment that includes the caregiving process, thus taking into consideration the family and resources as part of a care plan.
Dr. George Taler, president of AAHCP received some of his medical training in England with a group of geriatric specialists. He learned about house calls in coordination with family, nursing and “Friendly Visitors” care. He enjoyed this experience so much that he became involved in care at home. As Dr. Taler related, “there is a whole lot you can do when you see someone at home”. This concept is fully supported by both the National Association of Home Care and the American Geriatric Society (AGS). The formal position of AGS is, “Experience suggests that both the quality of medical care and the quality of life for patients can be improved by physicians making house calls”.
More and more medical schools are incorporating the house call experience into physician education and residency programs. The John A. Hartford Foundation along with Columbus Medical Association Foundation and the Jewish Healthcare Foundation, currently support the introduction of home care in ten medical schools across the nation. This hopefully means that more home care doctors will be available and will select performing house calls for the future. Dr. Taler, in addition to being president of AAHCP is also Director of Long Term Care at the Washington Hospital Center in Washington, D.C., and their brand new programs. He faces many challenges as he seeks to integrate house calls with existing ambulatory care, discharge planning and emergency room services.
What to Expect and How to Prepare for a Physician Home Visit
Although the place of visit changes from the office to the home, care should still be professional, courteous, and confidential. An assistant is likely to accompany the physician. Don’t be surprised to see portable high-tech equipment for diagnostic, testing and treatment services that provide nearly instant results. Many doctors use hand held or lap top computers for recording the findings and results of the in-home visits.
If the visit is the first one, be prepared with previous records and all medications. A summary of the medical history, possibly done ahead of time, is useful and makes it easier to be sure nothing is missed. It also avoids the task of trying to remember everything correctly. Offer the house call team a place to wash their hands. Make sure that the care receiver’s clothing is easy to remove during the physical exam. Provide access to an electrical outlet. Write down any questions ahead of time as well as specific directions for follow up. Evaluate your family’s ability to communicate with the doctor and office staff.
What To Look For in a Home Care Doctor
Selecting the right physician – and having the courage to communicate and change when it isn’t right – can make a difference in the health of everyone at stake. As the availability of physicians who make house calls increases, what should be the selection process for a service that meets family needs? For more than five years, Chris de Laurier, D.O. performed house calls throughout Southern California. Now an IBM executive, he states, “Convenient bad care in the home is worse than inconvenient good care in the office.” His advice to families includes:
- Use a service that employs local physicians
- Verify physician qualifications to be sure there is formal training in the appropriate specialty, for example as an internist or geriatrician
- Select a doctor who can “work” with the family
In addition to the above recommendations, AAHCP President, Dr. George Taler suggests also checking on hospital affiliations. Be wary of services that rely heavily on repeat diagnostic testing. Communication and the relationship between the family and the physician are so important that Dr. Taler recommends the caregiver or family interview the doctor before the first visit. This can be done directly by going to the office, by phone or through a third party.
How to Find A Doctor That Will Make House Calls
Almost any physician is capable of making a house call. There is nothing to lose by requesting your physician to make a home visit. The American Academy of Home Care Physicians offers information about doctors who make house calls and where they are located. If a doctor doesn’t make home visits now but perhaps is considering it in the future; the Academy is a valuable resource. They have a booklet available entitled “Making House Calls a Part of Your Practice”. You might want to share it with your doctor. Call 410-676-7966 or visit on the web, www.aahcp.org.
Connie Ford, co-author of the NFCA/Fortis Report, recently formed Family Caregiver Resources Group to focus on consulting and care coaching?. Connie is the FL NFCA coordinator, Advocacy Editor for Today’s Caregiver magazine and founder of Boca Raton Interfaith in Action that provides volunteer support services to people who are homebound and their caregivers. She is available at 561-394-2821 or connieford@msn.com.
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