May 25--Within minutes of his arrival at Diana Maine's West Kendall home, Dr. Patrick Kavanagh is sitting at his patient's dining room table, an assortment of blue-topped prescription medicine bottles between them. He reviews a notebook of blood pressure readings Maine has kept since his last visit a month ago, then wraps an electronic blood pressure cuff on her arm. They discuss the results.
Every day Kavanagh, trusty iPad in tow, sees between five and 10 patients like 83-year-old Maine, seniors with multiple chronic conditions who need care in their homes. His car is a portable medical office, and he has the ability to do practically anything on the road -- including EKGs and ultrasounds. He can even request a technician to visit a home with a portable X-ray machine.
Kavanagh, an internist, works for My Home Doctor, a group of Florida physicians who treat non-emergency medical conditions at home through various insurance companies. Many of their patients are elderly and on Medicare. If a doctor didn't come to see them, they likely would end up in the emergency room -- which typically costs more than a home visit.
"This is preventative medicine," Kavanagh says. "We're monitoring patients and keeping them out of urgent care and the ER."
House calls, once thought to be too time-consuming and not very cost-effective, are making a comeback as healthcare providers recognize that they're actually the answer to good care for patients who can't make it to a doctor's office. Medicare-paid house calls have been steadily increasing, according to government figures, and doctors report the same for non-Medicare patients, according to the American Academy for Home Care Physicians. What's more, technology has made accessibility to patients' records and other medical information available at any time and any place, a boon to physicians on the go.
Now a three-year federal government pilot program called Independence at Home is encouraging doctors to pick up those black medical bags of yore and pay a visit to their sickest patients. As part of the new healthcare reform law, the demonstration project will cover 10,000 Medicare patients described as medically fragile. It is set to begin in January in locations yet to be decided.
Why? House calls can make both financial and health sense. Experts say various hospital programs around the country, as well as pilot projects through insurance companies, show that treating patients at home improves outcomes and often prevents more expensive hospital involvement.
"Any primary care physician will tell you that as patients age, they find it harder and harder to come to the office," says Constance Row, executive director of the American Academy of Home Physicians, a Maryland-based organization that promotes care at home. "As a result their conditions worsen and many end up in the hospital for conditions that could have been handled and controlled at home."
In the past few years, the traditional practice of house calls received lots of attention -- including the USA Network "Royal Pains" TV show -- as doctors began to provide concierge services to patients who paid an annual membership fee for easy access. This kind of a medical practice usually involves wealthier patients who can afford to fork over the extra money.
MEDICARE
But house calls have also been growing for Medicare patients -- by more than 50 percent since 1995. This is a result of an increasing number of older people living longer with more chronic illnesses, as well as an awareness of the benefits of quickly treating a patient before a condition becomes life-threatening.
Consider this: Ten percent of Medicare recipients -- those with multiple chronic illnesses such as diabetes and heart disease -- account for two-thirds of Medicare's expenditures. Many of these seniors are unable to visit a doctor's office for maintenance care or for minor ailments. When the condition worsens, however, they end up in an urgent care facility.
The percentage of seniors needing at-home medical care is expected to double by 2025, as baby boomers head into their 70s and 80s, experts say. Jose Varona, managing partner of My Home Doctor, and his partner Mark Price saw an opportunity in those numbers. They launched their physician management company as a boutique 24/7 service in 2006 but shifted their attention to needier patients, many on Medicare. Several insurance companies, including Blue Cross/Blue Shield of Florida, contract with My Home Doctor to deliver home care around the state.
"This population and its needs will continue to grow," Varona predicts. "And insurance companies have realized that it costs considerably less to pay for a home visit than for an ER visit and certainly dramatically less than admission to a hospital."
Insurance companies are experimenting with different ways of delivering care at home to their sickest patients. Blue Cross/ Blue Shield launched a pilot program in 2009 for its homebound and seriously ill patients in South Florida to bring down emergency care core costs and frequent hospital re-admissions. Called PATCH (Physician Assessment Treatment and Care at Home), the program included 15 providers and 75 patients in Miami-Dade and Broward.
"This was for the very complex cases that make up a very small percentage of the population but incur a lot of the costs," says Jannifer Harper, vice president of medical operations. "We wanted to break that cycle."
The experiment worked by decreasing ER use while also improving patient satisfaction, so Blue Cross is expanding the program to Orlando and Tampa.
A TEAM
Another insurance company, Humana Cares, Humana's chronic care management division, provides personalized care to about 125,000 chronically ill Medicare Advantage members across the country. A Humana Cares team, which also includes social workers and community health educators, provides both telephone and home care management, says Humana spokesman Mitch Lubitz.
Earlier this year, Humana Cares also launched a 15-month national pilot in partnership with GE-Intel Care Innovations, a company that creates technology to encourage seniors' independence, to remotely monitor the health of 2,000 high risk congestive heart failure patients around the country by email, phone and web video chats.
Home health agencies have also tiptoed into the house call field. United HomeCare, which provides home healthcare to 5,000 elderly and disabled people in Miami-Dade, works with a handful of Miami physicians to schedule appointments for their homebound clients. One of them is Esther Rivera, 90, of Westchester.
Dr. Francisco A. Reytor began his monthly visits to Rivera and husband Miguel in October. When Miguel died in December, the visits became even more important when Reytor noticed Rivera had lost weight. Listless and unusually quiet, she confessed she wasn't hungry. He prescribed medicine for depression and she bounced back.
Reytor not only monitors her physical health but also asks about her social life. "I look forward to his visit," Rivera says. "He gives me a lot of encouragement."
Reytor, who sees about 200 patients at home, travels with an assistant, a laptop full of electronic medical records, and crates of equipment. His visits go beyond the medical and into "the psycho-social problems such as isolation.''
Reytor, trained as an emergency physician, began house calls 10 years ago, when he realized patients were leaving his ER without any plans for follow up care.
"When you're with them at home, you spend more time," he says. "You end up building a closer relationship."
As he gets ready to leave, Rivera asks, "Don't you want some coconut ice cream?"
House calls "are very instructive," says Robert Schwartz, chairman of the family medicine and community health department at the University of Miami's Miller School of Medicine. "You see patients in their environment."
Schwartz, who began making house calls when he was a resident in New York in the early 1980s, says he once spotted rugs that could have caused a fall for a patient and the need for handrails in the bathroom of another. These days, he visits patients at home as needed, usually when one of his regulars becomes homebound or is temporarily too sick to travel.
His schedule is unpredictable. One month he might not see any patients at home and then visit three in one week, depending on the circumstances.
His conversations with caregivers also help.
"In an office, you're under the gun and you rarely meet other family members who can provide valuable insight to the patient," he says.
"At home, you see what kind of support they have. It's a more holistic approach."
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